Form

Patient Questionnaire

First Name

Last Name

If you are a new patient, how did you hear about our office?

Emergency Contact Information. Please list name, relationship and phone number

Please list current employer and occupation or school attending

Preferred Pharmacy Name and Phone Number

When was your last physical exam with a physician?

Name of Doctor

Have you ever been told by a physician to take a pre-medication antibiotic before having a dental procedure done?

How long has it been since your last dental visit?

Reason for today's visit

Have you ever had any unfavorable reactions or complications following dental treatment?

Do your gums bleed when you brush or floss your teeth?

Are you aware of squeezing, grinding or clenching of your teeth?

Are you aware of any sores in your mouth?

Have you been treated for Periodontal "Gum" disease? If so, what kind of treatment?

If you could change anything about your smile, what would you change?

To ensure your visit is a great experience, please share any questions or concerns you would like us to know about.

PLEASE NOTE:

Piper Family Dentistry requires payment at the time of your treatment. For treatment plans requiring multiple appointments, alternate payment arrangements may be provided. By signing below, I accept full financial responsibility for this account and for all dentistry performed upon my dependents in this dental office. I understand that it is up to me to know my insurance eligibility, waiting periods, and benefits. I also understand that this office cannot guarantee my insurance status in any of these areas. Any insurance estimate or information given to me by this office is not a guarantee of actual insurance payment. I understand that any insurance claim not paid in full after 90 days will become my responsibility to pay at that time. I also agree to be responsible for the payment of all services rendered on my behalf or my dependents, and agree to any additional fees that may occur in the collection of my account.

SCHEDULING APPOINTMENTS:

Due to the time reserved with the Dentist or Hygienist for your appointment we require a deposit of $100.00 for any appointment over an hour or for treatment over $500. Our office requires a 48 business hour notice to cancel or reschedule any appointment. If insufficient notice is not given to reschedule or cancel your appointment this will result in forfeiture of all deposits. Some appointments do not require a deposit, but a patient will be charged a missed appointment fee of $100 if 48 business hour notice is not given. We do understand that circumstances do arise and we will take this into consideration at the time of the appointment.

I consent for medical photographs/videos to be taken of me or my dependents. I understand that they may be used for publication seen by the public without identifying information such as my last name. I also understand that it is possible that someone may recognize me and I will not receive payment from any party.

I give consent for Piper Family Dentistry to send communication either via text or email for marketing of products or services offered by the doctor or practice.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patients') health. It is my responsibility to inform the dental office of any changes in medical status.

Patient/Legal Guardian Signature