New Patient Form

Please fill out the form below. If you have any difficulty filling it out online, you may click the buttons below to download the PDF form. After completing the form, please email it over to info@altitudedentalfl.com.

New Patient Form

Financial Agreement

Patient Update Form

"*" indicates required fields

Step 1 of 11

Please complete the following confidential information...

Date*

MM slash DD slash YYYY

Full Name*

Salutation Patient First Name Patient Last Name

Date of Birth*

MM slash DD slash YYYY

SSN*

Spouse/Parent Name

Guardian or person responsible for patient

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Business Phone

Cell Phone*

Getting to know you...

Is another member of your family or relative a patient at our office?

YES

Relative Name*

Relationship*

Referred to us by

Person to contact for emergency

Contact for Emergency Phone number

Consent for Treatment...

Consent*

I agree to authorization.

I hereby authorize Altitude Dental or designated staff to take x-rays, study models, photographs, and any other diagnostic procedures needed for Altitude Dental or designated staff to make a thorough diagnosis of my dental needs.

Consent*

I agree to authorization.

Upon such diagnosis, I authorize Altitude Dental or designated staff to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

Consent*

I agree

I agree to the use of anesthetics, sedatives, and other medication, as necessary. I understand that using anesthetic agents embodies certain risks. I understand that I can ask for an explanation of any possible complications.

Date*

MM slash DD slash YYYY

Signature*

(Parent or Responsible Party )

MEDICAL HISTORY

Patient Name

Nickname

Age

Name of Physician/and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?*

Excellent

Good

Fair

Poor

Do you have or have you ever had:

Hospitalization for illness or injury

YES

Hospitalization for illness or injury details

Please describe

An allergic or bad reaction to any of the following:

Allergies

Aspirin, Ibuprofen, Acetaminophen, Codeine

Penicillin

Erythromycin

Tetracycline

Sulfa

Local anesthetic

Fluoride

Chlorhexidine (CHX)

Iodine

Metals (Nickel, Gold, Silver, )

Latex

Nuts

Fruit

Milk

Red dye

Other

Please describe

Heart problems, or cardiac stent within the last six months

YES

heart problems, or cardiac stent within the last six months detail

Please describe

History of infective endocarditis

YES

History of infective endocarditis detail

Please describe

Artificial heart valve, repaired heart defect (PFO)

YES

Artificial heart valve, repaired heart defect (PFO) detail

Please describe

Pacemaker or implantable defibrillator

YES

Pacemaker or implantable defibrillator detail

Please describe

Orthopedic or soft tissue implant (e.g joint replacement, breast implant)

YES

Orthopedic or soft tissue implant (e.g joint replacement, breast implant) detail

Please describe

Heart murmur, rheumatic or scarlet fever

YES

Heart murmur, rheumatic or scarlet fever detail

Please describe

High or low blood pressure

YES

High or low blood pressure detail

Please describe

A stroke (taking blood thinners)

YES

A stroke (taking blood thinners) detail

Please describe

Anemia or other blood disorder

YES

Anemia or other blood disorder detail

Please describe

Prolonged bleeding due to a slight cut (or INR > 3.5)

YES

Prolonged bleeding due to a slight cut (or INR > 3.5) detail

Please describe

Pneumonia, emphysema, shortness of breath, sarcoidosis

YES

Pneumonia, emphysema, shortness of breath, sarcoidosis detail

Please describe

Chronic ear infections, tuberculosis, measles, chicken pox

YES

Chronic ear infections, tuberculosis, measles, chicken pox detail

Please describe

Breathing problems (e.g. asthma, stuffy nose, sinus congestion)

YES

Breathing problems (e.g. asthma, stuffy nose, sinus congestion) detail

Please describe

Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)

YES

Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting) detail

Please describe

Kidney disease

YES

Vertigo (e.g. ”the room is spinning”)

YES

Liver disease or jaundice

YES

Diabetes (HbA1c = )

YES

Diabetes (HbA1c = ) detail

Please describe

Thyroid, parathyroid disease, or calcium deficiency

YES

Thyroid, parathyroid disease, or calcium deficiency detail

Please describe

Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)

YES

Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome) detail

Please describe

High cholesterol or taking statin drugs

YES

High cholesterol or taking statin drugs detail

Please describe

Stomach or duodenal ulcer

YES

Stomach or duodenal ulcer detail

Please describe

Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)

YES

Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia) detail

Please describe

Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)

YES

Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates) detail

Please describe

Arthritis or gout

YES

Arthritis or gout detail

Please describe

Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)

YES

Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma) detail

Please describe

Glaucoma

YES

Contact lenses

YES

HIV/AIDS

YES

Head or neck injuries

YES

Head or neck injuries detail

Please describe

Epilepsy, convulsions (seizures)

YES

Epilepsy, convulsions (seizures) detail

Please describe

Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)

YES

Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease) detail

Please describe

Viral infections and cold sores

YES

Viral infections and cold sores detail

Please describe

Any lumps or swelling in the mouth

YES

Any lumps or swelling in the mouth detail

Please describe

Hives, skin rash, hay fever

YES

Hives, skin rash, hay fever detail

Please describe

STI/STD/HPV

YES

STI/STD/HPV detail

Please describe

Hepatitis (type)

YES

Hepatitis (type) detail

Please describe

Tumor, abnormal growth

YES

Tumor, abnormal growth detail

Please describe

Radiation therapy

YES

Radiation therapy detail

Please describe

Chemotherapy, immunosuppressive medication

YES

Chemotherapy, immunosuppressive medication detail

Please describe

Emotional difficulties

YES

Emotional difficulties detail

Please describe

Psychiatric treatment or antidepressant medication

YES

Psychiatric treatment or antidepressant medication detail

Please describe

Concentration problems or ADD/ADHD

YES

Concentration problems or ADD/ADHD detail

Please describe

Alcohol/recreational drug use

YES

Alcohol/recreational drug use detail

Please describe

ARE YOU:

Presently being treated for any other illness

YES

presently being treated for any other illness detail

Please describe

Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)

YES

Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea) detail

Please describe

Taking medication for weight management

YES

Taking medication for weight management detail

Please describe

Taking dietary supplements, vitamins, and/or probiotics

YES

Taking dietary supplements, vitamins, and/or probiotics detail

Please describe

Often exhausted or fatigued

YES

Often exhausted or fatigued detail

Please describe

Experiencing frequent headaches or chronic pain

YES

Experiencing frequent headaches or chronic pain detail

Please describe

A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis

YES

A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis detail

Please describe

Considered a touchy/sensitive person

YES

Considered a touchy/sensitive person detail

Please describe

Often unhappy or depressed

YES

Often unhappy or depressed detail

Please describe

Taking birth control pills

YES

Currently pregnant

YES

Diagnosed with a prostate disorder

YES

Diagnosed with a prostate disorder detail

Please describe

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

Drug

Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Signature*

Patient’s Signature

Date*

MM slash DD slash YYYY

DENTAL HISTORY

Patient Name*

Nickname

Age

Referred by

How would you rate the condition of your mouth?

Excellent

Good

Fair

Poor

Previous Dentist

How long have you been a patient? (Months/Years)

Date of most recent dental exam

MM slash DD slash YYYY

Date of most recent x-rays

MM slash DD slash YYYY

Date of most recent treatment (other than a cleaning)

MM slash DD slash YYYY

I routinely see my dentist every

3 months

4 months

6 months

12 months

Not routinely

WHAT IS YOUR IMMEDIATE CONCERN?

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY:

1- Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [____]

YES

1- Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) detail

Please describe

2- Have you had an unfavorable dental experience?

YES

2- Have you had an unfavorable dental experience detail

Please describe

3- Have you ever had complications from past dental treatment?

YES

3- Have you ever had complications from past dental treatment detail

Please describe

4- Have you ever had trouble getting numb or had any reactions to local anesthetic?

YES

4- Have you ever had trouble getting numb or had any reactions to local anesthetic detail

Please describe

5- Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

YES

5- Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age detail

Please describe

6- Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

YES

6- Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma detail

Please describe

GUM AND BONE

7- Do your gums bleed sometimes or are they ever painful when brushing or flossing?

YES

7- Do your gums bleed sometimes or are they ever painful when brushing or flossing detail

Please describe

8- Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?

YES

8- Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth detail

Please describe

9- Have you ever noticed an unpleasant taste or odor in your mouth?

YES

9- Have you ever noticed an unpleasant taste or odor in your mouth detail

Please describe

10- Is there anyone with a history of periodontal disease in your family?

YES

10- Is there anyone with a history of periodontal disease in your family detail

Please describe

11- Have you ever experienced gum recession, or can you see more of the roots of your teeth?

YES

11- Have you ever experienced gum recession, or can you see more of the roots of your teeth detail

Please describe

12- Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

YES

12- Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple detail

Please describe

13- Have you experienced a burning or painful sensation in your mouth not related to your teeth?

YES

13- Have you experienced a burning or painful sensation in your mouth not related to your teeth detail

Please describe

TOOTH STRUCTURE

14- Have you had any cavities within the past 3 years?

YES

14- Have you had any cavities within the past 3 years detail

Please describe

15- Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

YES

15- Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food detail

Please describe

16- Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

YES

16- Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth detail

Please describe

17- Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

YES

17- Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth detail

Please describe

18- Do you have grooves or notches on your teeth near the gum line?

YES

18- Do you have grooves or notches on your teeth near the gum line detail

Please describe

19- Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

YES

19- Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling detail

Please describe

20- Do you frequently get food caught between any teeth?

YES

20- Do you frequently get food caught between any teeth detail

Please describe

BITE AND JAW JOINT

21- Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

YES

21- Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) detail

Please describe

22- Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

YES

22- Do you feel like your lower jaw is being pushed detailback when you try to bite your back teeth together detail

Please describe

23- Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

YES

23- Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods detail

Please describe

24- In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

YES

24- In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed detail

Please describe

25- Are your teeth becoming more crooked, crowded, or overlapped?

YES

25- Are your teeth becoming more crooked, crowded, or overlapped detail

Please describe

26- Are your teeth developing spaces or becoming more loose?

YES

26- Are your teeth developing spaces or becoming more loose detail

Please describe

27- Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?

YES

27- Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together detail

Please describe

28- Do you place your tongue between your teeth or close your teeth against your tongue?

YES

28- Do you place your tongue between your teeth or close your teeth against your tongue detail

Please describe

29- Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

YES

29- Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits detail

Please describe

30- Do you clench or grind your teeth together in the daytime or make them sore?

YES

30- Do you clench or grind your teeth together in the daytime or make them sore detail

Please describe

31- Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

YES

31- Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth detail

Please describe

32- Do you wear or have you ever worn a bite appliance?

YES

32- Do you wear or have you ever worn a bite appliance detail

Please describe

SMILE CHARACTERISTICS

33- Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?

YES

33- Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display) detail

Please describe

34- Have you ever bleached (whitened) your teeth?

YES

34- Have you ever bleached (whitened) your teeth detail

Please describe

35- Have you felt uncomfortable or self conscious about the appearance of your teeth?

YES

35- Have you felt uncomfortable or self conscious about the appearance of your teeth detail

Please describe

36- Have you been disappointed with the appearance of previous dental work?

YES

36- Have you been disappointed with the appearance of previous dental work detail

Please describe

Signature*

Patient’s Signature

Date

MM slash DD slash YYYY

Broken Appointment Policy

When creating appointments, we make every effort to coordinate your personal schedule with ours-ensuring specific, predictable, and individual time is set aside to care for you in the best way possible. In return, we ask that you make every effort to keep your agreed upon dental appointment. If your dental appointment needs to be changed, we kindly ask to be notified at least 24 hours before the appointment. If an appointment is altered within that 24-hour time period, we may consider that as a “broken” appointment.

At Altitude Dental, we consider the following scenarios as “broken” appointments:

A cancellation with less than 24 hours’ notice.
- For Monday appointments, notice must be given on the Thursday before.
When a patient does not show up for their appointment.
When a patient shows up 15 minutes past the appointment time.

We do understand that some situations are uncontrollable, and exceptions may be made on an individual basis.

If a broken appointment occurs, a missed appointment fee of 50.00 will be assessed to your account. Please know that we do not take pleasure in assessing these fees, however we take pride in dedicating specific time frames in our schedule in order to deliver high quality care to you and your family. In addition, if more than 3 broken appointments exist on your account, you will be required to pay in full to reserve your next appointment.

Signature*

PLEASE RETAIN THIS STATEMENT FOR FUTURE REFERENCE. IF YOU DO NOT UNDERSTAND THE POLICIES SET FORTH, PLEASE ASK FOR AN EXPLANATON. OUR TEAM WILL BE HAPPY TO DISCUSS YOUR CONCERNS.

Financial Information

Thank you for choosing Altitude Dental. We are committed to providing you a comfortable, relaxed experience, as well as the best oral health care provided anywhere. Your clear understanding of our financial policy is important to our professional relationship, so we ask that you read, initial as indicated, and sign.

Payment is due at the time of service. If your treatment requires special payment arrangements, our financial coordinator will be happy to work this out with you prior to beginning your treatment. We accept: Cash, Check, MasterCard, Visa, Discover, American Express, Debit Cards, and CareCredit.

Person Financially Responsible for the Account:

Name:*

Relationship to Patient:

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Date of Birth

MM slash DD slash YYYY

SSN*

Do you have dental insurance?

We will file your insurance as a courtesy to you; however, we do not take it as a form of payment. Payment is due at the time of service. If you have insurance, please provide us with your card, as well as your driver’s license or other form of identification with a photo ID. To assure your information is always current and accurate, please report any changes in personal information or insurance changes.

1) Initial

We make no claim to know what services your insurance plan covers. While we make a good faith attempt to verify coverage, we are not able to guarantee that the information given to us by your insurance is correct. It is your responsibility to know what services may or may not be covered by your insurance. We encourage you to refer to your benefits manual if you have any questions regarding covered services. In addition, be aware that some of the services may not be

2) Initial

Insurance Claims Processing:

The office will supply factual information to facilitate claim processing. Your insurance policy is a contract between you and your insurance company.

3) Initial

Out of Network and PPO Plans:

We are considered out of network for all plans. We are happy to bill your insurance company as a courtesy to you, but payment is due at the time of service.

4) Initial

Patient Release for Records:

I hereby authorize Altitude Dental, to release to my insurance company any necessary information needed to file and expedite payment on my claim.

5) Initial

Returned Checks:

There will be a $25.00 charge for all bank returned checks. If a second check is presented and returned, we will require future payments to be made by cash or credit card.

6) Initial

Patient Payment:

I have read, understand, and abide to the terms stipulated above. I have requested clarification of any parts or parts of this financial agreement that I do not understand. I agree to be fully responsible for total payment of procedures performed in this office. I agree that should this account be referred to an attorney or agency for collection, I will be responsible for all collection costs, attorney fees, and court costs. I, the undersigned, have read the above and assume the responsibility for my account.

7) Initial

Patient Name*

Date*

MM slash DD slash YYYY

Signature*

Signature of Person Financially Responsible for this Account

CONSENT FOR RELEASE OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. These rights have been outlined in our office’s Notice of Privacy Practices (NOPP).

I have reviewed the NOPP, been given an opportunity to ask questions about it, understand it and do hereby agree to its terms. A copy of this signed, dated consent shall be as effective as the original. I release the practice, its employees, and agents for any and all disclosures as stated in the NOPP.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment of health care operations and super-confidential information. 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.

I hereby authorize Altitude Dental to use and disclose any necessary information from my dental record, verbally, faxed, emailed or by mail, in accordance with our Notice of Privacy Practices.

Patient Name*

Date*

MM slash DD slash YYYY

Signature*

Social Media Consent / Release Form For News Media, Promotional Materials, Written Articles, Research and/or Photographs

YES

I hereby authorize the office of Altitude Dental to use my photo and/or information related to my experiences with their office. I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, letters to area legislators and media and/or other similar ways. The office of Altitude Dental will disclose to me or my legal representative, where appropriate, the specific information and/or photo to be used prior to release in the social media. My consent is freely given as a public service to the office of Altitude Dental without expecting payment. I release the office of Altitude Dental and their respective employees, officers, and agents from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, videotape and/or photographs.

I prefer that:

My complete name be used

My first name only be used

No name be used

I understand that I can revoke this release any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease.

Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Date

MM slash DD slash YYYY

Signature

The signature of a parent of legal guardian is required if the above individual is under the age of 18 or in not competent.

Phone

This field is for validation purposes and should be left unchanged.

New Patient Form

Please complete the following confidential information...

Getting to know you...

Consent for Treatment...

MEDICAL HISTORY

Do you have or have you ever had:

An allergic or bad reaction to any of the following:

ARE YOU:

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

DENTAL HISTORY

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY:

GUM AND BONE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS

Financial Information

Person Financially Responsible for the Account:

Insurance Claims Processing:

Out of Network and PPO Plans:

Patient Release for Records:

Returned Checks:

Patient Payment:

CONSENT FOR RELEASE OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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