New Patient Kit
Please fill out as completely as possible before your
first visit and bring these in with you to our office.
CONTENTS:
Patient Information Form
Medical History Form
Dental History Form
HIPAA Consent Form
Patient Financial Policy Form
Copyright © Bobcat Dental. All Rights Reserved.
PATIENT REGISTRATION
ID:
Chart ID:
Last Name:
First Name:
Patient Is:
Middle Initial:
Preferred Name:
Policy Holder
Responsible Party
Responsible Party (if someone other than the patient)
First Name:
Last Name:
Address:
Middle Initial:
Address 2:
City, State, Zip:
Pager:
Home Phone:
Work Phone:
Birth Date:
Ext:
Cellular:
Soc Sec:
Drivers Lic:
Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information
Address:
Address 2:
State / Zip:
City:
Home Phone:
Sex:
Work Phone:
Male
Other
Birth Date:
Pager:
Ext:
Marital Status:
Female
Age:
Married
Cellular:
Single
Divorced
Soc. Sec:
Separated
Widowed
Drivers Lic:
I would like to receive correspondences via e-mail.
E-mail:
Section 3
Referred By:
Additional Comments:
Section 2
Employment Status:
Student Status:
Full Time
Full Time
Part Time
Retired
Previous Dentist:
Part Time
Emergency Contact:
Medicaid ID:
Pref. Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
Pref. Hyg.:
Emergency Contact #:
Physcian:
Physcian #:
Primary Insurance Information
Relationship to Insured:
Name of Insured:
Insured Soc. Sec:
Spouse
Child
Other
Self
Spouse
Child
Other
Insured Birth Date:
Employer:
Ins. Company:
Address:
Address:
Address 2:
Address 2:
City,State,Zip:
City,State,Zip:
Rem. Benefits:
Self
.00
Rem. Deduct:
.00
Secondary Insurance Information
Relationship to Insured:
Name of Insured:
Insured Soc. Sec:
Insured Birth Date:
Employer:
Ins. Company:
Address:
Address:
Address 2:
Address 2:
City,State,Zip:
City,State,Zip:
Rem. Benefits:
.00
Rem. Deduct:
.00
Bobcat Dental, PLLC
MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
following questions.
Are you under a physician's care now?
Yes
No If yes, please explain:
Have you ever been hospitalized or had a major operation?
No If yes, please explain:
Yes
Have you ever had a serious head or neck injury?
Yes
No If yes, please explain:
Are you taking any medications, pills, or drugs?
Yes
No If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Women: Are you
Pregnant/Trying to get pregnant?
Yes
No
Taking oral contraceptives?
Yes
No
Nursing?
Yes
No
Are you allergic to any of the following?
Aspirin
Other
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
If yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Have you ever had any serious illness not listed above?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No If yes, please explain:
Comments:
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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
What is your main concern about your teeth? _______________________________________________
______________________________________________________________________________________
If you could change anything about your teeth, what would it be? _______________________________
______________________________________________________________________________________
Are you interested in whitening your teeth? Yes or No
When was your last visit to the dentist? ____________________________________________________
What was done at that time? _____________________________________________________________
How often do you have your teeth professionally cleaned? ____________________________________
Do you floss? Yes or No How often? ______________________________________________________
What kind of toothbrush do you use? Manual or Electric
Do your gums bleed either in chewing, brushing or at any other time? Yes or No
Explain: ______________________________________________________________________________
Have your gums ever been treated? Yes or No If yes, when? __________________________________
Do you have pain or soreness in your teeth or gums? Yes or No
Does food catch between your teeth? Yes or No If yes, where? ________________________________
Are any of your teeth sensitive to sweets? Yes or No
Are any of your teeth sensitive to temperature? Yes or No
Are any of your teeth sensitive to pressure? Yes or No
Do you suffer from any headaches or migraines on a regular basis? Yes or No
Do you notice popping or clicking in your jaw when you open or close? Yes or No
Do you clench or grind your teeth? Yes or No
Do you have a tired feeling in your face while chewing or any particular time during the day? Yes or No
Have you had any wisdom teeth removed? Yes or No
Have you had any teeth removed? Yes or No
If yes, are you interested in replacing any missing teeth? Yes or No
Have you had orthodontic treatment? Yes or No
Patient Name: _____________________________________ _____________________________________
(Signature)
(Please Print Name)
Date: ___________________________________________________________________________________
Reviewed by: _________________________________________________________________________
Notice of Privacy Practices Acknowledgement
Bobcat Dental
Alan J. Brunelli, D.D.S.
1060 South Preston Road Suite 110
Celina, Texas 75009
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I
have certain rights to privacy regarding my protected health information. I understand that this
information can and will be used to:
o
o
o
Conduct, plan and direct my treatment and follow-up among the multiple healthcare
providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician
certifications
I acknowledge that I have received your Notice of Privacy Practices containing a more complete
description of the uses and disclosures of my health information. I understand that this
organization has the right to change its Notice of Privacy Practices from time to time and that I
may contact this organization at any time at the address above to obtain a current copy of the
Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or
disclosed to carry out treatment, payment or health care operations. I also understand you are
not required to agree to my requested restrictions, but if you do agree then you are bound to
abide by such restrictions.
Patient Name:
_________________________
Relationship to Patient: _________________________
Signature:
_________________________
Date:
_____________
Office Use Only
I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy
Practices Acknowledgement, but was unable to do so as documented below:
Date
Initials
Reason
BOBCAT DENTAL
DR. ALAN J. BRUNELLI
FINANCIAL POLICY
This statement is to inform you of our financial policy. We are committed to providing you with the
highest quality dental care using only the best material and technology available in the market today. We
are also committed to providing you with up-to-date information and educational tools so that you may
fully participate in maintaining optimum oral health. Our financial policy is intended to facilitate
excellent service to you while minimizing our administrative costs.
All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize
that as your dental care provider, our relationship is with you, our patient, not with your insurance
company. Your insurance policy is a contract between you, your employer, and the insurance company.
Our office is not a party to that contract. If payment from your insurance company is not received within
60 days from date of service, you will be expected to pay the balance in full.
As a courtesy to you we will help you process all your insurance claims. In order for our office to file
your insurance claim, you must provide complete and accurate dental insurance information. Any
changes in dental insurance must be provided in order to process your claims.
Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard,
Visa, American Express, Care Credit and Flex Checks 90.
Returned checks and balances older than 60 days may be subject to collection fees and finance charges.
Additionally, our office will charge you for missed appointments and appointments cancelled
without 24-hour advance notice. A $25.00 fee will be charged to your account for any missed
appointment and must be paid in order to schedule any future appointments.
If you have any questions regarding our financial policy, please ask. We are committed to providing you
with the most positive experience in dental care.
_______________________________
Print Name
_______________________________
Signature
1060 S. Preston Rd. Suite #110 Celina, Texas 75009
________________________
Date
(972) 382-2900-Office (972) 382-2906- Fax