Patient Information

First_________________________________________ Middle Initial _______ Last _______________________________________

SSN: ___________________________ Date of Birth _____________________ Email ______________________________________

Address: ___________________________________________ City: _____________________ State: ______ Zip: _______________

Home Phone: _________________________________ Cell Phone: __________________________________ Sex: ⃝ M ⃝ F

Do you prefer appointment confirmations via (check one or both): TEXT MSG ___ or PHONE CALL ___

Marital Status: ⃝ Single ⃝ Married ⃝ Divorced ⃝ Widowed ⃝ Separated

Employer: ____________________________________________________ Phone Number: _______________________________

Who can we thank for referring you to us ? ________________________________________________________________________

In Case of Emergency Contact Information: __________________________________________ Phone: ______________________

Reason for visiting us today: ____________________________________________________________________________________

Pharmacy Name / Number: ___________________________________________________ Allergies: _________________________

Are you interested in whitening your teeth? ______

Primary Dental Insurance

Person Responsible for Account: ________________________________________________________________________________

Relationship to Patient: _____________________________________ Date of Birth: __________ SSN: ______________________

Insurance Company: _______________________________________ Subscriber ID: _______________________________________

Employer: _____________________________________________________ Group #: ____________________________________

Insurance Company Address: __________________________________________ Phone: __________________________________

Notice of Privacy Practices Acknowledgment

HIPPA

Dove Dentistry

977 State Hwy 121 Suite 190

Allen, TX 75013

972-649-7990

I understand that, under Health Insurance Portability & Accountability Act of 1996 (HIPPA), I

have certain rights to privacy regarding my protected health information. I understand that this

information can and will be used to:

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 have received, read and understand this Notice of Privacy Practice that contains a complete

description of the uses and disclosure of my health information. I understand that this

organization has the right to change its Notice of Privacy Practice time to time and that I may

contact this organization at anytime at the address above to obtain a copy of Notice of Privacy

Practice.

I understand that I may request in writing that you restrict how my private information is used

or disclosed to carry out treatment, payment and or healthcare 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: ________________________

General Dentistry Consent Form

Dove Dentistry

977 State Hwy 121 Suite 190

Allen, TX 75013

972-649-7990

____ Treatment to be done

I understand that I am to have dental work done as detailed in the attached treatment plan.

Dove Dentistry will file your insurance claims, however, you are responsible for all fees which are not

paid by your insurance company.

_______ Drugs and Medications I understand that antibiotics, analgesics, and other medications can cause allergic reactions

such as redness, swelling of tissue, pain, itching, vomiting, and/or analgesic shock (severe allegoric

reaction). I have informed the dentist of any known allergies to medications. Women are advised that

antibiotics may interfere with the effectiveness of birth control pills. Other means of contraception

while taking antibiotics is recommended.

_______ X-rays

I have been explained about the necessity of taking x-rays to have a thorough comprehensive

exam. I will not hold the doctor liable nor responsible if any diagnosis arising without the necessary

x-rays.

_______ Changes in Treatment Plans

I understand that it may be necessary to change or add procedures because of conditions

found while working on the teeth. If this occurs the procedure will be stopped and the following

changes will be explained to me and new consent form will be signed before continuing with the new

treatment.

___________________________________________________________________________________

Patient Signature/ Parent / Guardian Date

Cancelation Policy

If an office appointment is missed or canceled with less than one business day

notice, a $25.00 fee will be assessed to your account.

It is very important to notify our office of any cancellation as early as possible so

your time slot can be offered to another patient. Your cooperation is appreciated.

If a procedure appointment is missed or cancelled with less than two business days’

notice, a$50.00 fee will be assessed to your account.

Any exceptions will be discussed on an individual basis.

I have read and understand the cancelation policy for Dove Dentistry.

Patient Name Printed:________________________________________________________

Patient’s Signature______________________________ Date___________________

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Dentsply International Raintree Essix 7290 26th Court East | Sarasota, FL 34243

Ideal Smile QuestionnairePlease take a few moments to tell us about your smile.

YES NO

Have you thought about improving the appearance of your smile?

Would you like to straighten your teeth?

Do you have spaces that you don’t like?

Would you like to change the color of your teeth?

Are your teeth chipped?

Are your teeth wearing on the biting surfaces?

What would you change about your teeth? (Circle all that apply)

Color Shape Size Straighten Other: