New Patient Form

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Name *

First

Middle

Last

Preferred Phone Number *

Email Address *

Confirm Email

Electronic Communication Consent *

I agree that Smile Corners Dental may communicate with me electronically at the phone number and email address above. I can withdraw my consent to electronic communications by calling (970) 688-8838, or emailing info@smilecorners.com.

Mailing Address *

Date of Birth *

Gender

Occupation

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Emergency Contact Relationship *

What is your preferred method of communication? *

Phone Call
Text Message
Email

How did you hear about us? *

Referral
Google
Facebook
Instagram
Drive by
Other

If you are completing this form for another person, what is your name and relationship?

If completing this form as the patient's personal representative

If completing this form as the patient's personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient.

Dental History & Symptom: What is the reason for your visit? *

Describe any dental pain or discomfort you currently have, put N/A if not applicable *

When was your last dental exam? *

What was done at that appointment? *

Are you interested in cosmetic dentistry?

Color/ whitening
Shape
Position
Overall smile

Medications: Are you taking or scheduled to take any medications? *

Blood thinners (such as Coumadin, Warfarin, rivaroxaban (Xarelto), dabigatran (Pradaxa), clopidogrel (Plavix), heparin or aspirin)
Medication to treat osteoporosis or Paget's disease
IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer
Tobacco or nicotine products or controlled substances (drugs), including marijuana, for either medicinal or recreational reasons
Other prescriptions and/or over-the-counter medicines
None

Please list the medications you are currently taking, including how much and how often you use each one.

Women Only: Are you currently pregnant? If yes, number of weeks

Medical History: Do you have, or have you been diagnosed with, any of the following conditions? *

Heart (Cardiac) Health
Breathing (Respiratory) Health
Cancer
Blood (Circulatory) Health
Brain (Neurological)/ Mental Health
Autoimmune Disease
Digestive Health
Eye (Vision) Health
Other
None

Please describe your medical conditions

Allergies: Are you allergic to, or have you had an allergic reaction to *

Aspirin
Sulfa drugs such as Septra, Bactrim, Azulfidine, Eryzole, Pediazole, Diabeta, Glynase PresTabs, Imitrex, Celebrex, Microzide or Lasix
Barbiturates, sedatives or sleeping pills
Codeine or other narcotics
Hay fever, seasonal allergies
Iodine
Latex (rubber)
Local anesthetics
Metals
Penicillin, or other antibiotics
Other
None

Please describe any allergies answers, and include information about your experience

It is important for both the dcotor and patient to talk honestly about the patient's health before dental treatment starts. *

I have answered the above questions completely, accurately and to the best of my ability.

Financial Policy *

I have read and agree to this Financial Policy: We are committed to providing you with the highest quality of care. We will communicate all recommended treatment options and associated fees, prior to the start of treatment. Payment is due at the time of treatment. We are commited to respecting your time and ask that you make every effort to keep the appointment time reserved to you. We understand there may be times when you are unable to keep your scheduled appointment; however, missed appointments may be subject to a fee of $50. Should you find it necessary to reschedule an appointment, please provide us with 48 hours notice to avoid being charged a missed appointment fee. The insurance relationship constitutes an agreement between the carrier and the patient. As such, we can make no guarantee of estimated coverage or payment. Actual benefits paid will be subject to your insurance policy at the time the claim is processed. As a courtesy to our patients we will sbumit your insurance claim and provide any necessary information to assist you in receiving your dental benefits.

HIPAA Notice of Privacy Practices *

I have read and agee to the HIPAA Notice of Privacy Practices. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We may use and disclose our health information for different purposes, including treatment, payment and health care operations, such as when required by law, national security, worker's compensation, law enforcement, judicial and administrative proceedings, coroners, medical examiners, and funeral directors. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, letters, or text messages). You have the right to look at or get copies of your health information, with limited exceptions. If you want more information about our privacy practices or have questions or concerns, please contact us.

ADA Code

D110

D120

D140

D150

D160

Procedure Description

Initial Oral

Oral Examination

Emergency Oral

Comprehensive

intraoral

Office Fee

$40

$45

$41

$46

$55

Gold Member Fee

$35

$42

$40

$50

Platinum Member Fee

$38

$44

$43

$41

$52

New Patient Form

New Patient Form

ADA Code

Procedure Description

Office Fee

Gold Member Fee

Platinum Member Fee

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