Downtown Dallas Dentistry > New Patient Forms

New Patient Forms

 

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Appointment Cancellation and “No Show” Appointments

As a courtesy we routinely remind and confirm patients of their upcoming scheduled appointment, usually the day before and either directly or by a phone message if they are away from their desk. If unable to keep appointment, we request 24 hours notice.

First cancellation or No-Show: No charge. This is entered into the file, but is considered excused.

Second event: A charge will accrue and is payable before another appointment can be made.

Third event: So as not to raise fees for everyone to compensate for this expense by a few, we need to talk.

Steven G. Stutsman, DDS

NameYour full name
Signature
Date
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES


You can view and print our Privacy Policy by clicking HERE.


“You May Refuse to Sign This Acknowledgement”

I,

Name

have received a copy of this office’s

Notice of Privacy Practices.

Name
Signature
Date
For office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

     ____ Individual refused to sign

     ____ Communications barriers prohibited obtaining the acknowledgement

     ____ An emergency situation prevented us from obtaining acknowledgement

     ____ Other (Please specify)







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About Dental Insurance

Facts you should know about Dental Insurance.


Dental insurance is rapidly playing a larger and larger role in helping people obtain dental treatment. Since we strongly feel our patients deserve the best possible dental care we can provide, and in an effort to obtain the high quality of care, we would like to share some facts about dental insurance with you.


Fact #1: Dental insurance is NOT meant to be a PAY-ALL; it is only meant to be an aid.


Fact #2:  Many plans tell their insured that they will be covered “up to 80% or up to 100%. In spite of what you may have been told, we have found most plans cover about 60% to 70% of an average fee. Some plans pay more-some less. The amount your plans is determined by how much your employer paid for the plan. The less he paid for the insurance, the less you will receive.


Fact #3: It has been the experience of many dentists that some insurance companies tell their customers that “fees are above usual and customary fees” rather than saying to them that “our benefits are low”. Remember – you get back only what your employer puts in less the profits of the insurance company.


Fact #4: Many routine dental services are NOT covered by insurance carriers.


Please do not hesitate in asking us any questions about our office policies. We want you to be comfortable in dealing with these matters and we urge you to consult us if you have any questions regarding our services and/or fees. We will file your insurance forms at no charge.


Although this office will do everything possible to maximize your insurance benefits. You are ultimately responsible for any portion of your account balance not paid by your insurance company, regardless of the reason.


If you have any questions regarding your insurance, we ask that you contact your company regarding the specifics and details of the plans it is conducting in your behalf.


Steven G. Stutsman, DDS

NameYour full name
Signature
Date
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1 Patient Info
2 Patient 2
3 Emp & Ins
4 Dental
5 Medical

New Patient Form

Patient Information

Patient Name
DOB
Pt SSN
Preferred Phone
Work Phone
Cell Phone
Home Phone

Home Address

Home Address
City
State
Zip
How long at address
_
Marital Status
_
Spouse Name
Names and Ages of Children
0 /
Emergency Contact Name
Relationship
Emergency Phone
Who may we thank for referring you?

Employer Information

Employer Name
Occupation
How Long with Employer
Work Fax

Insurance Information

Insurance Name
Ins Address
Ins City
Ins State
Ins Zip
Plan/Group Number
Insurance Phone
Name of Insured
Insurance ID #
Insured Name
Ins DOB
Insured Employer
Insured SSN

Dental Information

Previous Dentist
How Long Since Last Visit
Are you satisfied with your past dental treatment?
Are you happy with your smile?
What would you change if you had the opportunity? Please describe below
0 /
Do you experience pain?
When did this start?
Can you describe the pain?
0 /
Do you have any problems with your gums?
Do they bleed?
How often do they bleed?
Are you apprehensive about dental treatment?
What in particular bothers you?
0 /
Have you used nitrous oxide gas when having dental treatment?

As I plan any treatment for you, are you most comfortable controlling problems before they get more serious (Proactive), or waiting until you become aware of the problem through pain, sensitivity or breakage (Reactive)?

Controlling Problems
What do you consider to be the dentists' role in maintaining your dental health?
0 /
How often do you brush?
How often do you floss?
How can we serve you better or improve your visit?
0 /
Is the arrangement and/or alignment of your teeth satisfactory in appearance and function?
0 /

Medical Information

Are you sensitive or allergic to any medications?
Please list sensitivities or allergies here.
0 /
Are you taking any medications at this time
Please list any medications you are currently taking here.
0 /
Are you using any recreational drugs?
... any over-the-counter drugs?
Do you smoke or use tobacco products?
Health HistoryPLEASE CHECK ALL OF THE FOLLOWING THAT APPLY
Do you wear a Cardiac pacemaker?
Have you had heart surgery?
JOINT REPLACEMENT(S)
Joint Replacement Description (When/Where)?
0 /
Is there a possibility that you could be pregnant?
Have you taken any steriods in the last 6 months?
Have you ever had any serious illness, operations or hospitalizations?
0 /
Are you under a physician's care?
Physician Name
Physician Phone
Last Exam Date
Is there any additional information that you would like for me to know to better care for your dental health?
0 /
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