Save Time By Completing The New Patient Form Online

If you are a new patient, please fill out form below. Our office will have all the information when you come to your assigned clinic.

Welcome to Professional Dental

New Patient Information

Did you make an appointment?

First Name

Last Name

Preferred Name

Birthdate

Age

PD Office

SSN#

Sex

Mailing Address

City

State

ZIP Code

Home Phone

Work Phone

Cell Phone

Email Address

Employer

Status

Spouse's Name

How Many Children under 14?

How Many Children above 14?

Name Of Emergency Contact

Emergency Phone

Guarantor Of The Account

Relationship To Patient

Mailing Address

State

City

Zip Code

Home Phone

Work Phone

Cell Phone

Birthdate

Employer

SSN #

Insurance Name

Group #

ID#

Insurance Phone #

Insurance Address

Employer

Work Phone

Name Of Policy Holder

DOB Of Policy Holder

SSN #

Relationship To Patient

Physician

Office Phone

Date Of Last Visit

Are You Under Medical Treatment Now?

If Yes, Please Explain

Have You Been Hospitalized Within The Last 5 Years?

If Yes, Please Explain

Are You Taking Medications, Including Blood Thinners?

If Yes, Please List

Ever Taken Bisphosphaonates?

If Yes, How Long?

Have You Taken Phen Fen?

Use Controlled Susbstances?

Do You Use Tobacco?

If Yes, How Used & How Long?

Are You Allergic Or Have You Had Any Reactions To The Following?

Local Anesthetics

Yes No

Penicillin / Antibiotics

Yes No

Latex Rubber

Yes No

Any Metals

Yes No

Codeine

Yes No

Other

Yes No

Do You Currently Have Or Have You Ever Had Any Of The Following?

AIDS / HIV

Yes No

Anemia

Yes No

Asthma

Yes No

Cancer

Yes No

Cardiac Pacemaker

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy / Convulsion

Yes No

Fainting

Yes No

Glaucoma

Yes No

Hay Fever / Allergies

Yes No

Heart Attack

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Hepatitis / Jaundice

Yes No

High Blood Pressure

Yes No

Joint Replacement

Yes No

Kidney Disease

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prol.

Yes No

Radiation Therapy

Yes No

Respiratory Problems

Yes No

Rheumatic Fever

Yes No

Seizures

Yes No

STI/STD

Yes No

Stomach Troubles

Yes No

Stroke

Yes No

Swollen Ankles

Yes No

Thyroid Problem

Yes No

Tuberculosis

Yes No

Sleeping And Breathing

Do You Usually Wake Feeling Tired?

Yes No

Do You Habitually Snore?

Yes No

Do You Headaches Frequently Wake You Up?

Yes No

Do You Experience Daytime Drowsiness?

Yes No

Has Anyone Observed You Stop Breathing While Alseep?

Yes No

Do You Have Blocked Nasal Passages?

Yes No

Do You Grind Your Teeth While Asleep?

Yes No

Do You Ever Wake Up Choking Or Gasping?

Yes No

Women Only

Are You Pregnant Or Do You Think You Might Be Pregnant?

Yes No

Are You Nursing?

Yes No

Are You Taking Contraceptives?

Yes No

Previous Dentist

Previous Clinic

How Many Times A Day Do You Brush?

How Many Times A Week Do You Floss?

How would you rate your smile?

Require Antibiotic Pre-Medications?

I accept to share this information with Professional Dental & Orthodontics and I confirm I read terms & Conditions

Full Name - (Your name is valid as your signature)

Relationship to patient

Consent to Proceed

I authorize Professional Dental and/or such associates or assistants as he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments.

I understand that the administration of local anesthetic may cause an outward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval.

I understand that as part of the dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. After lengthy appointments, jaw muscles may also be sore or tender. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required.

I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal.

I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past, such as Phen-Fen. I understand that taking the class of drugs for the prevention of

osteoporosis, such as Fosamax, Boniva, Actonel, may result in complications of non-healing of the jawbones following oral surgery or tooth extractions.

I do voluntarily assume any and all possible risk of substantial and serious harm, if any, which may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions. I also acknowledge that all of the preceding answers and information provided on all forms filled out are true and correct. If I ever have any change in my health or there are changes in my child's health, I will inform Professional Dental at the next appointment without fail. If changes are not reported, I agree that any damage incurred will be my sole responsibility, financially and legally. I acknowledge that I have the right to refuse treatment at which time I must sign the proper refusal forms. I agree that I will be responsible for any damage incurred if prescribed treatment is not rendered within the reasonable prescribed amount of time.

I understand and accept Professional Dental Consent Form

Full Name - (Your name is valid as your signature)

Relationship to patient

Financial Policy

We are happy you have chosen Professional Dental as your dental provider. We accept many different insurances to benefit our patients. As a condition of your treatment by this office, financial arrangements must be made in advance. This practice depends upon the reimbursement from our patients for the costs incurred in their care, to remain viable. Therefore, financial responsibility on the part of each patient must be determined before treatment.

Patients who carry dental insurance understand that it is their responsibility to provide correct/updated insurance information. All dental services rendered are charged directly to the patient and that he or she is personally responsible for payment of all services. Professional Dental is happy to submit insurance forms and help resolve outstanding claims to the insurance company designated by you. You must understand that not all insurance companies pay in full for estimated services rendered. However, regardless of insurance coverage, I agree that it is and shall remain my responsibility to pay all amounts owing as set forth herein.

I agree that interest will accrue on all past-due amounts at the rate of 18% per annum (1.5% per month) until paid in full. In the event any amount(s) is/are referred to a third party debt collection agency, I agree that in addition to any other amount(s) allowed for by law, (such as interest, court costs, reasonable attorney's fees, etc.) I will also be responsible for a collection fee of up to 40% of the principal amount(s) owing as allowed by Utah Code Annotated, sec.12-1-11. The terms of this paragraph shall apply to all amount(s) incurred by me or by any individual for whom I have legal responsibility whether such amount(s) are incurred today or after today.

I hereby consent to being contacted by telephone at any telephone number (including but not limited to wireless/cellular phone numbers) provided by me or anyone associated with me or acting on my behalf to Professional Dental or anyone acting on its behalf. I understand and agree that such calls may be initiated by Professional Dental or any of its affiliates, agents, contractors or assigns, including but not limited to billing companies and/or third-party collection agency(ies), and that the methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automated dialing device and/or the use of text messages—some or all of which may result in data charges. I also consent to receiving e-mails at any e-mail address provided by me or anyone associated with me or acting on my behalf.

I agree that if payment cannot be made at the time of service, treatment may be denied and I am responsible for any costs incurred. I agree that any verbal agreement for payment is a legal agreement and I will be held to such agreements until the balance of my account is paid off. I understand that there will be $25 charge on all returned checks. I understand that after one check is returned, the only method of payment this office can accept is cash or credit. I understand that 24-48 hours' notice is required to cancel an appointment. In order to keep costs low, I agree that I must be at each appointment as agreed and scheduled. A minimum of a $60 charge will be made for broken or failed appointments.

I understand and accept Professional Dental Financial Policy

Full Name - (Your name is valid as your signature)

Relationship to patient

Privacy Practices

I acknowledge that I have received a copy or had the opportunity to read Professional Dental's Privacy Policy (Hippa agreement). I hereby agree to abide by the condition outlined herein. (You may refuse to sign this acknowledgment).

I understand and accept Professional Dental Privacy Practices Policy

Full Name - (Your name is valid as your signature)

Relationship to patient

By signing, I aknowledge and approve forms of Professional Dental

Digital Signature

* By providing my information, I agree that I am sharing personal and medical information to Professional Dental & Orthodontics. I understand Professional Dental & Orthodontics does not share my information with third parties and all data provided will be treated as confidental information.

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New Patient Form

Save Time By Completing The New Patient Form Online

New Patient Information

Download The Form Here To Fill It Out Manually.

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