HOW WERE YOU REFERRED TO OUR OFFICE?
Name
___________________________
SELECT UP TO 3 CHOICES AND PLACE THEM IN ORDER OF 1,2, AND/OR 3
ON HOW YOU MADE THE DECISION TO COME TO OUR OFFICE.
Cedar Rd Medical Assoc
Children's Dentistry Offices
DentalPlans.com
Dinner & A Movie Voucher
Dr.Pearl’s Postcard/Newspaper Announc
Elementary Schools CH
Elementary Schools VB
Employers
Facebook
Family Member
Fitness Centers
Friends
Health Fair Events
Insurance Companies
Internet Search:
Konikoff Dentistry Website____ Other Website(Please List)_________
Klar and Voorhees
Konikoff Periodontics
Miranda, Josue D MD
Nimmo Pediatrics
Office Location/Signage
Other Orthodontic Office
Other Physician's Office
Postcards
Roy Orthodontics
Television Commercial
Tricare
Twitter
Urgent Care Facilities
Walk In
Yellow Pages
Patient Information (CONFIDENTIAL)
Konikoff Dental Associates, Inc.
Date ___________________
Circle:Male/Female
Check Appropriate Box:
Patient's Social Security # ______________________
Child
Single
Married
Age: __________
Divorced
Widowed
Separated
Birthdate: __________________
Name____________________________________________________________ Home Phone ___________________
Home Address____________________________________________City____________________State________Zip_________
Email Address____________________________________________ Cell Phone _____________________________
Patient’s Employer___________________________________________ How Long? ___________ Work Phone____________
Patient's Employer Address______________________________________ Position___________________________________
City _____________________________________ State _____ Zip_________
If Student, Name of School/College _______________________City ___________State_____ Part Time Full Time
Has anyone in your family been seen at any of our office locations? If yes, who______________________________
Person to Contact in Case of Emergency________________________________ Phone______________________
Family Information
Spouse / Parent or Guardian Name ________________________________S.S.#__________________ Birthdate_______
Address ____________________________________City ____________________________ State __________ Zip ________
Spouse or Parent's Employer __________________________ Spouse or Parent's Work Phone ________________________
Additional Parent or Guardian Name ______________________________S.S.#___________________ Birthdate________
Address ____________________________________City ____________________________ State __________ Zip ________
Spouse or Parent's Employer __________________________ Spouse or Parent's Work Phone ________________________
Dental Insurance Information
Circle: Employer coverage or Individual plan
Subscriber Name __________________________________________________ Birthdate __________________
Relationship to patient___________________
Social Security # _______________________________ Date employed ___________
Name of Employer ______________________________________ Union or Local # ______ Work Phone ________________
Address of Employer _____________________________________ City ____________________ State _______ Zip________
Insurance Company Name __________________________________ Group # ______________ Policy/ID #____________
Insur. Co. Address _______________________________________ City _____________________ State _______Zip________
Insur. Co. Telephone Number: ______________________
Do you have any additional Dental Insurance ? Yes
No
If yes, complete the following:
Subscriber Name __________________________________________________ Birthdate __________________
Relationship to patient_________________________
Social Security # _______________________________ Date employed ___________
Name of Employer ______________________________________ Union or Local # ______ Work Phone ________________
Address of Employer _____________________________________ City _____________________State _______Zip________
Insurance Company Name __________________________________ Group # ______________ Policy/ID #_____________
Insur. Co. Address _______________________________________ City _____________________State _______Zip________
I ALLOW THE FOLLOWING INDIVIDUALS TO DISCUSS MY FINANCIAL, MEDICAL AND/OR DENTAL
INFORMATION WITH EMPLOYEES OF KONIKOFF DENTAL ASSOCIATES.
PLEASE PRINT FULL NAMES: _____________________________,______________________________
Page 1 of 3
Dental Information
Reason for today's visit:  Exam  Emergency  Consultation Are you in pain?  No  Yes How Long? _______
Is there anything about your dental needs we should focus on: _________________________________________________
Previous Dentist: ___________________________________________ (_______) _________________________
name
phone
Last Dental exam: ________________________________ Last Dental X-rays: _________________________
How would you rate your smile? 1 2 3 4 5 6 7 8 9 10
Medical Information
Physician__________________________________ Office Phone __________________ Date of Last Exam ___________
1. Are you under medical treatment now?  Yes or  No
If yes, please explain_________________________________
________________________________________________________________________________________________
2. Are you taking any medication(s) including non-prescription medicine? Yes or No.
If yes, please list _______________________________________________________________________________
3. Are you currently taking or have you ever taken any of the following medication either orally or through IV?
Fosamax
Didrone
Boniva
Aredia
Actonel
Skelid
Zometa
4. Have you had any surgeries?  Yes or  No
If yes, please list: _______________________________________
5. Do you have ANY DRUG, LATEX or FOOD ALLERGIES?  Yes or  No
If yes, please list:______________
_________________________________________________________________________________________________
6. Do you use tobacco?  Yes or  No
How used? ________________ How much?______ How long?_______
7. Have you ever used or are currently using recreational drugs?
 Yes or  No
8. FOR WOMEN ONLY: Are you taking Birth Control pills?  Yes or  No
Are you Pregnant?  Yes  No Approx. Delivery Date ________ Are you nursing?  Yes  No
9. CIRCLE BELOW If you have or have had any of the following diseases or medical conditions:
Alcohol/Drug Abuse
Diabetes/Hypoglycemia
Hepatitis
Psychiatric Problems
Aggressive Steroid Therapy  Difficulty Breathing
Rheumatic Fever 
High Blood Pressure
HIV+/AIDS/ARC 
Anemia
Emphysema
Rheumatoid Arthritis
Artificial Bones/Joints 
Scarlet Fever 
Epilepsy
Jaw Problems TMJ
Artificial Valves 
Joint Replacement 
Fainting/Seizures
Sinus Problems
Kidney Problems 
Stents/shunts 
Asthma
Frequent Headaches
Bleeding Problems
Frequent Neck Pain
Leukemia
Stomach Ulcers
Cancer 
Stroke

Glaucoma
Liver Problems
Chemotherapy 
Heart Attack 
Lupus 
Tuberculosis TB 
Heart Disease 
Mitral Valve Prolapse 
Chest Pains
Venereal Disease
Congenital Heart Defect 
Heart Murmur 
Osteoporosis
High Cholesterol
Heart Surgery 
Defibrilator
Pacemaker
Other: ____________
Please notify our office immediately if you have/have had any of the conditions, marked with a . We may need written
authorization from your physician to treat you.
X-RAYS - We pride ourselves in delivering the highest standard of care; therefore complete diagnostic x-rays are
necessary. We require complete series of x-rays on our new patients. If you have had this series in the past three
years we ask that you bring them with you on your initial visit.
 Notice to test blood. A law was enacted in Virginia in 1989 which authorized health care providers to test their patients
for HIV antibodies when the health care provider is ACCIDENTALLY EXPOSED to blood or body fluids in a manner
which may transmit the human immunodeficiency virus (HIV). However, you would be informed before any of your
blood would be tested for HIV antibodies. The testing would be explained and you would be given the opportunity
to ask any questions you might have. In addition, in the event that one of our health care providers is exposed to
potentially infectious body fluids, permission is hereby granted to test my blood for infectious Hepatitis B.
Page 2 of 3
FINANCIALINFORMATION–PLEASEREADCAREFULLY.
Itisthegoalofourpracticetoprovidenotonlythefinestcareavailable,butalsotoprovidefinancial
servicesthatdonotcauseunduehardships.Patientswillbescheduledfortreatmentafterfinancial
arrangementsaremadewithourFinancialAssociatesregardingalltreatment.OURFINANCIAL
ASSOCIATESAREAVAILABLETOANSWERANYQUESTIONSYOUHAVE.
Ourofficerequiresa24hournoticeifyouarenotabletomakeyourappointment.Ifwedonotreceive
thisnotice,afeewillbechargedtoyouraccount.
X‐rayRequirements‐‐Weprideourselvesindeliveringthehigheststandardofcare;therefore,
completediagnosticx‐raysarenecessary.Werequireacompleteseriesofx‐raysonnewpatientsand
patientswhohavenotbeentoseeusonaregularbasis.Ifyouhavehadthisseriesdonewithanotherdentist
inthepastthreeyears,weaskthatyoubringthemwithyouonyourinitialvisit. IF YOU DO NOT
HAVE THEM OR ARE NOT ABLE TO RETRIEVE THEM FROM YOUR PRIOR DENTIST
BEFORE YOUR APPOINTMENT WITH US, WE WILL NEED TO TAKE X-RAYS AND
BILL YOU.
InsurancePolicy—Thepatientisalwaysexpectedtopayhis/herportionatthetimeofservice,
includingco‐payanddeductibles.Asacourtesytoallofourpatientswithinsurance,wewillfiledental
serviceswithyourprimaryinsurancecompany,andifapplicableyoursecondaryinsurance.Thenormal
timeallowedforinsuranceresponseis30days.Anychargesremainingonyouraccountafteryour
insurancepaysareultimatelyyourresponsibility.
PaymentPolicy‐Ourofficerequirespaymentinfullforallservicesrenderedatthetimeofvisit,
unlessotherarrangementshavebeenmadewiththefinancialdepartment.Ifotherarrangementsaremade
withourfinancedepartment,thepatientauthorizesKonikoffDentalAssociates,Inc.tomakesuchinquiries
withanycreditbureauregardingfinancialresponsibilitiesthataredeemednecessary.
CollectionPolicy‐Ifyouraccountbecomesdelinquentandnofinancialarrangementshavebeen
made,youwillberesponsibleforlegalfees,interestcharges,331/3%attorneyfees,andanyotherexpenses
incurredincollectingyouraccountbalance.Allworkmustbepaidinfullatthetimeofserviceonceyour
accounthasbeensatisfiedwiththeattorney.
AUTHORIZATIONSFROMPATIENT
IauthorizeKonikoffDentalAssociates,Inc.toperformanynecessaryservicesneededduringdiagnosisand
treatment.Ialsoauthorizethereleaseofanyrequiredinformationtooutsidehealthpractitionersandforthepurpose
ofprocessinginsuranceclaims.
Iunderstandthatmyinsurancepolicyisacontractbetweenmeandmyinsurancecompany ies andthatIam
responsibletoKonikoffDentalAssociates,Inc.forallfees.
Iauthorizeandrequestmyinsurancecompany ifapplicable topaydirectlytothedentistordentalgroup
insurancebenefitsotherwisepayabletome.Iunderstandthatmydentalinsurancecarriermaypaylessthanthe
actualbilledservicesandthatIamresponsiblefortheremainingbalance.
Iunderstandtheaboveinformationandguaranteethisformwascompletedcorrectlytothebestofmy
knowledgeandunderstanditismyresponsibilitytoinformthisofficeofanychangestotheinformationIhave
provided.
Signature_______________________________________________Date_____________
______AdultPatient______ParentorGuardian______Spouse’sSignature PowerofAttorneyRequired Page 3 of 3