Welcome Form

39-09 210th St
Bayside, NY 11361
P: (718) 225-4888

1. About You

Today's Date:
File Number:
Patient's First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Gender:
Age:
SSN:
Mailing Address:
City:
State:
Zip:
Home Phone #:
Work Phone #:
Cell Phone #:
E-Mail Address:
Referred By:
Employer:
How Long?
Employer's Address:
City:
State:
Zip:
Occupation:
Status: 
Spouse's Name: 
Do You Have Children?
Number Of Children
 

2a. Insurance Information - Primary Dental Insurance

Company Name:
Company Address:
Phone #:
Insured's ID #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Date of Birth:
Primary Insured's Employer:
 

2b. Insurance Information - Secondary Dental Insurance

Company Name:
Company Address:
Phone:
Insured's ID #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Date of Birth:
Insured's Employer:
 

3. Account Information

Name:
Relation:
Billing Address:
City:
State:
Zip:
SS #:
 
Drivers License #:
Work Phone #:
Payment Method:
 
I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).

4. In Event of Emergency

Whom should we contact?
Relation:
Home Phone #:
Work Phone #:
Cell Phone #:
 
Who is your Medical Doctor?
Medical Doctor's Phone #:

5. Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication
Are you under physician's care now?

Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have taken, Phen-Fen or Redux?
Have you ever take Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
​​​​​
Are you on a special diet?
Do you use tobacco?
Women are you...


Are you allergic to any of the following?


Other?
If Yes
Do you use controlled substances?
If Yes
Do you have, or have had, any of the following?
 
AIDS/HIV Positive
Cortisone Medicine
Alzheimer's Disease
Diabetes
Anaphylaxis
Drug Addiction
Anemia
Easily Winded
Angina
Emphysema
Arthritis/Gout
Epilepsy or Seizures
Artificial Heart Valve
Excessive Thirst
Artificial Joint
Fainting Spells/Dizziness
Asthma
Frequent Cough
Blood Disease
Frequent Diarrhea
Blood Transfusion
Frequent Headaches
Breathing Problems
Genital Herpes
Bruise Easily
Glaucoma
Cancer
Hay Fever
Chemotherapy
Heart Attack/Failure
Chest Pains
Heart Murmur
Cold Sores/Fever Blisters
Heart Peacemaker
Congenital Heart Disorder
Heart Trouble/Disease
Convulsions
Hemophilia
Hepatitis A
Radiation Treatments
Hepatitis B or C
Recent Weight Loss
Herpes
Renal Dialysis
High Blood Pressure
Rheumatic Fever
High Cholesterol
Rheumatism
Hives or Rash
Scarlet Fever
Hypoglycemia
Shingles
Irregular Heartbeat
Sickle Cell Disease
Kidney Problems
Sinus Trouble
Leukemia
Spina Bifida
Liver Disease
Stomach/Intestinal Disease
Low Blood Pressure
Stroke
Lung Disease
Swelling of Limbs
Mitral Valve Prolapse
Thyroid Disease
Osteoporosis​​​
Tonsilitis
Pain in Jaw Joints
Tuberculosis
Parathyroid Disease
Tumors or Growths
Psychiatric Care
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed
Additional Comments:

6. Dental Information

Reason for today's visit:
Are you in pain?
How Long?
Please indicate any of the following problems:











Other
Do you require pre-medication?
Previous Dentist Name:
Phone Number:
Last Dental Exam: 
Last Dental X-rays: 
Times a day you brush?
Times a week you floss?
What type of toothbrush bristles do you use?
How would you like to rate your smile?

Dental Cosmetic Questionnaire

In order to evaluate your needs and expectations as accurately as possible, please help us by answering the following question, circle any words that may apply, and provide us with any additional information.

When I see a picture of myself, the first thing I notice about my smile is:
Do you like the color of your teeth? (dark, dull, stained, mismatched?)
Do you feel that your teeth are too small or too short?
Do you feel that your teeth are too large or too long?
Are your teeth crooked or out of line?
Are these spaces between your teeth you don't like?
Do you show a lot of gum tissue when you smile?
Are your gums irregularly shaped (higher or lower on some teeth)?
Are the biting edges of your teeth uneven, worn down, or chipped?
Do your teeth slant one way or another?
Is the midline of your upper two front teeth centered with your nose?
Have your gums receded?
Are there any dental filling or crowns that don't match your teeth or look ugly?
Are any of your teeth missing?
Do you feel that your smile is too narrow?
Do you feel that you don't show enough teeth when you smile?
Is there anything else about your smile or teeth that you don't like, would like to change or would like us to know about?
 

Vital Dental of Bayside

PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Vital Dental to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).
  • Obtaining payment from third party payers (e.g. my insurance company).
  • The day-to-day health care operations of your practice.

I have also been informed of , and given the right to review and secure a copy of the Vital Dental Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry our treatment, payment, and health care operations, but that Vital Dental is not required to agree to these requested restrictions. However, if Vital Dental does agree, Vital Dental is then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use of disclosure that occurred prior to the date I revoke this consent is not affected. Unless you object, Vital Dental may disclose to a member of your family, a relative or any other person you identify, your personal health information that directly relates to that person's involvement in your health care.

 
Please print patient name:
Please print parent/guardian name:

NOTICE OF PRIVACY FOR PROTECTED HUMAN INFORMATION

VITAL DENTAL OF BAYSIDE

APPOINTMENTS

We value your time so you can expect us to see you at the appointment time and to keep your time spent in our waiting area as sort as possible. In return, when you make an appointment with us please be on time since we have reserved our time just for you. Please make every effort not to change your scheduled appointment. In the event you must change your appointment, please provide us at least 2 business days of advanced notice so that we may use your time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. We value your time, please value ours. A fee of 50$ may be charged for appointments broken, changed or rescheduled with less than 36 hours notice.

FINANCIAL POLICY

Unless another financial option is pre-arranged, payment in full is due the day of treatment. Should a patient have dental insurance with assigned to Vital Dental, the estimated patient portion with be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full.

Payment Options

  1. For your convenience we accept: Cash, Check, Visa, Mastercard, American Express & Care Credit.
  2. We also offer short and long-term financing options.

For patients with Dental Insurance

Dental Insurance plans often pay less than actual fee for service, therefore the patient or guarantor is the responsible party for all dental services provide. Dental insurance, in most cases, is a benefit with limitations and should not be explained to you during your initial appointment or during a separate treatment discussion/consultation appointment. I also authorize to keep my signature on file with Vital Dental in order to process dental insurance claims on my behalf.

Finance Charge and Fees

  1. Balances in excess of 90 days without prior arrangements will be charged a 15% interest.
  2. Returned checks are subject to a $35 accounting fee.

AUTHORIZATION AND CONSENT

General Consent To Treatment

Release Of Information

Assignment Of Insurance Benefits

Patients are responsible to set up assignment of benefits with their insurance.

I understand and will comply with the Vital Dental Appointment Policy.

I understand and will comply with the Vital Dental Financial Policy

I understand and agree to the General Consent To Treatment.

I authorize the Release Of Information.

Photography Release Vital Dental

Signature: