Patient Information Form

Please fill out the form completely

Step 1 of 10

10%

Date*
Date Format: MM slash DD slash YYYY
How did you find us?*
- Internet Search
- One of our valued patients
- Advertisement
- Local Dental Society
Please provide the name of the client that referred you*
Patient Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Please omit dashes and brackets
Work Phone
Home Phone
Address*
Street Address City State / Province / Region ZIP / Postal Code
Social Security Number*
Please omit dashes and brackets
Date of Birth*
Date Format: MM slash DD slash YYYY
Employer
Occupation
Company Address
Street Address City State / Province / Region ZIP / Postal Code
Sex*
- Male
- Female
Marital Status*
- Married
- Single
- Divorced
- Separated
- Widowed
Emergency Contact*
Relationship to Patient*
Emergency Contact Phone*

Dental Benefit Plan Information
Do you have a Dental Insurance Plan?*
- Yes
- No
Primary Dental Plan Name*
Insurance Carrier Phone*
Insurance Carrier Address*
Street Address City State / Province / Region ZIP / Postal Code
Name of Insured*
First Last
SSN/ID Number*
Date of Birth of Insured*
Date Format: MM slash DD slash YYYY
Patient Relationship to Insured
Do you have a Secondary Dental Insurance Plan?*
- Yes
- No
Secondary Dental Plan Name*
Insurance Carrier Phone*
Insurance Carrier Address*
Street Address City State / Province / Region ZIP / Postal Code
Name of Insured*
First Last
Date of Birth of Insured*
Date Format: MM slash DD slash YYYY
SSN/ID Number*
Patient Relationship to Insured

Patient Responsibilities: We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities.

Payment: Payment is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. We accept the following forms of payment: Cash, Check, Credit Card (MasterCard, Visa, Amex & Discover).

Dental Benefit Plans: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you and your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.

If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient's portion (deductible, co-insurance, copay, or any other amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.

If we are not a contracted provider with your dental benefit plan, it is the patient's responsibility to verify with the plan whether the plan allows patients to receive reimbursement services form out-of-network providers. If you plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you "assign benefits" to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if that amount is different from our estimated patient portion of the bill. If you choose to not "assign benefits" to our practice, you are responsible for filing claims and obtaining reimbursement directly from your dental benefit plan and will be responsible for payment to our practice before or at the time of service.

Scheduling of Appointments: We reserve the doctor and hygienist's time on the schedule for each patient procedure and are diligent about being on-time. Because of this courtesy, when a patient cancels an appointment, it impacts the overall quality of the service we are able to provide. To maintain the utmost service and care, we do require a 48 hour notice to reschedule and appointment. With less than 48 hour notice, a fee may be required to reserve the time again. To serve all our patients in a timely manner, we may need to reschedule an appointment if a patient is more than fifteen minutes late or more arriving to our practice. To reschedule an appointment due to late arrival, a fee may be required to reserve the appointment time again.

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be combined in such email may be misdirected, disclosed to or intercepted by, unauthorized theird parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount of protected health information in any communication. Our first email to you will verify the address you provide.
Email Notification Consent
- I consent and accept the risk in receiving information via email. I understand I can withdraw my consent at any time.
- I consent to receiving appointment reminders via email or text. I understand I can withdraw my consent and any time.
- I do not consent to receiving any information via email (with the exception of email confirmation of this form) . I understand that I can change my mind and provide consent later.

Authorizations: I understand that the information I have given today is correct to the best of my knowledge. I authorize this dental team to perform any necessary dental services that I may need and have consented to during diagnosis and treatment. (Please Type your Initials below.)*
I have read the above and agree to the financial and scheduling terms. (Please type your initials below.)*
I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered.*
- Yes
- No
I understand that I am financially responsible for all charges whether or not paid by insurance. I further understand that a finance charge of 1 ½% (18%) annually will be applied to any balance over 30 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note.*
I hereby acknowledge that a copy of this practice's Notice of Privacy Practices will be made available to me via email upon completion and submission of this form. I have been given the opportunity to ask any questions I may have regarding this Notice. (Please Initial Below.)*
I hereby acknowledge that a copy of this practice's Dental Materials Fact Sheet will be made available to me via email upon completion and submission of this form. I have been given an opportunity to aks questions I may have regarding this fact sheet.(Please Initial Below).*
Please sign using your finger, touchpad or mouse.*

Confidential Health History
Is your general health good?*
- Yes
- No
Briefly Explain:*
Has there been a change in your health within the last year?*
- Yes
- No
Briefly Explain:*
Have you gone to the hospital or emergency room or had a serious illness in the last three years?*
- Yes
- No
Briefly Explain:*
Are you being treated by a physician right now?*
- Yes
- No
Briefly Explain:*
Have you had problems with prior dental treatment?*
- Yes
- No
Briefly Explain:*
Are you in pain now?*
- Yes
- No
Briefly Explain:*
Date of Last dental Exam
Date Format: MM slash DD slash YYYY
Name of last treating dentist
First Last

Have you experienced any of the following?
Chest Pain*
- Yes
- No
Blood in stools*
- Yes
- No
Frequent Vomitting*
- Yes
- No
Fainting Spells*
- Yes
- No
Diarrhea or constipation*
- Yes
- No
Jaundice*
- Yes
- No
Recent Significant Weight Loss*
- Yes
- No
Frequent Urination*
- Yes
- No
Dry Mouth*
- Yes
- No
Fever*
- Yes
- No
Excessive Thirst*
- Yes
- No
Difficulty Urinating*
- Yes
- No
Night Sweats*
- Yes
- No
Ringing in Ears*
- Yes
- No
Difficulty Swallowing*
- Yes
- No
Persistent Cough*
- Yes
- No
Headaches*
- Yes
- No
Swollen Ankles*
- Yes
- No
Coughing up blood*
- Yes
- No
Dizziness*
- Yes
- No
Joint Pain or Stiffness*
- Yes
- No
Bleeding Problems*
- Yes
- No
Blurred Vision*
- Yes
- No
Shortness of Breath*
- Yes
- No
Blood in Urine*
- Yes
- No
Bruise Easily*
- Yes
- No
Sinus Problems*
- Yes
- No

Have you had or do you have any of the following?
Heart Disease*
- Yes
- No
Cosmetic Surgery*
- Yes
- No
Eating Disorders*
- Yes
- No
Family History of Heart Disease*
- Yes
- No
Surgeries*
- Yes
- No
Osteoporosis*
- Yes
- No
Heart Attack*
- Yes
- No
Hospitalization*
- Yes
- No
Thyroid Disease*
- Yes
- No
Artificial Joint*
- Yes
- No
Diabetes*
- Yes
- No
Asthma*
- Yes
- No
Stomach Problems or Ulcer*
- Yes
- No
Family history of diabetes*
- Yes
- No
Hepatitis*
- Yes
- No
Heart Defects*
- Yes
- No
Tumors or Cancer*
- Yes
- No
Sexual Transmitted Disease*
- Yes
- No
Heart Murmurs*
- Yes
- No
Chemotherapy*
- Yes
- No
Herpes*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Radiation*
- Yes
- No
Canker of Cold Sores*
- Yes
- No
Skin Disease*
- Yes
- No
Athritis, Rheumatism*
- Yes
- No
Anemia*
- Yes
- No
Hardening of Arteries*
- Yes
- No
Emphysema or other lung disease*
- Yes
- No
Liver Disease*
- Yes
- No
High blood pressure*
- Yes
- No
Kidney or Bladder Disease*
- Yes
- No
Eye Disease*
- Yes
- No
Seizures*
- Yes
- No
Stroke*
- Yes
- No
Transplants*
- Yes
- No
Tuberculosis*
- Yes
- No
This information will not be released unless specifically authorized by patient.
AIDS/HIV*
- Yes
- No
Anxiety*
- Yes
- No
Depression*
- Yes
- No
Treatment for Emotional Condition*
- Yes
- No

Are you allergic or have you had a reaction to any of the following?
Asprin*
- Yes
- No
Valium*
- Yes
- No
Tetracycline*
- Yes
- No
Darvon*
- Yes
- No
Demerol*
- Yes
- No
Vicodin*
- Yes
- No
Codeine*
- Yes
- No
Penicilin*
- Yes
- No
Percodan*
- Yes
- No
Latex*
- Yes
- No
Food*
- Yes
- No
Nitrous Oxide*
- Yes
- No
Local Anesthetic (Novocain or Xylocaine*
- Yes
- No
Erythromycin*
- Yes
- No
Metal*
- Yes
- No

Are you taking or have you taken any of the following in the last three months?
Recreational Drugs*
- Yes
- No
Tobacco in any form*
- Yes
- No
Antibiotics*
- Yes
- No
Over-the-counter medicines*
- Yes
- No
Alcohol*
- Yes
- No
Supplements*
- Yes
- No
Weight loss medications*
- Yes
- No
Bisphosphonate*
- Yes
- No
Aspirin*
- Yes
- No
Cortico - Steroids*
- Yes
- No
Please list all medications you are currently taking:
Women Only - Complete this part
Are you or could you be pregnant?
- Yes
- No
What Month?
Are you nursing?
- Yes
- No
Are you taking birth control pills?
- Yes
- No

Final Section for All Patients
Do you have or have you had any other diseases or medical problems NOT listed on this form?*
- Yes
- No
Briefly Explain*
Have you ever been pre-medicated for dental treatment?*
- Yes
- No
Briefly Explain*
Have you ever taken Fen-Phen?*
- Yes
- No
When did you take Fen-Phen?*
Is there any issue or condition that you would like to discuss with the dentist in private?*
- Yes
- No
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician:*
- Yes
Physician's Name
Physician's Phone
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form (please sign below)*

Office Information

Ackerman & Towson Dentistry
100 Cortona Way Suite 200
Brentwood CA 94513
925-684-7722

OFFICE HOURS

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

8am to 5pm
7am to 4pm
11am to 7pm
9am to 6pm
8am to 5pm
8am to 1pm

Dental Services

Preventive (Oral Disease Prevention)
Cosmetic (Esthetic Treatments)
Restorative (Repairing Teeth)
Periodontics (Gum Treatment)
Orthodontics (Braces)
Dental Implants
Dental Implant Information from AAID

APPLY FOR CARE CREDIT

Follow us on the Web

MAKE A PAYMENT

We accept Cash, Check, Visa, Mastercard, American Express and Discover. You can also make a secure payment conveniently online using the payment button below.

Enter Amount:

Merchant Account

Step 1 of 10

Dental Benefit Plan Information

Confidential Health History

Have you experienced any of the following?

Have you had or do you have any of the following?

Women Only - Complete this part

Final Section for All Patients