DSNForms

Bear Canyon Periodontics - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

*Street Address 1

Street Address 2

Apt.

*City

*State

*Zip

*Primary Phone

Alternate Phone (Mobile, work, or home)

General Dentist/Referring Office

*First Name

*Last Name

*Practice Name

Medical Doctor Information

Clinic Name

*Phone Number

*First Name

*Last Name

Clinic/Office Address

Pharmacy Information

*Preferred Pharmacy Name

Pharmacy Address

*Pharmacy Phone Number

Upload Information Section

Upload your Driver's license

Maximum allowed size : 25MB

Upload your insurance card

Maximum allowed size : 25MB

Upload the back your insurance card

Maximum allowed size : 25MB
Primary Dental Insurance Information

*Employer / Business

*Phone Number

*Plan Name

*Ins. Company Name

*Policy I.D. Number

*Ins. Company Address 1

Insurance Company Address 2

*City

*State

*Zip

Phone Number

Group Name

Group Number

*Do you have secondary dental insurance?

Health history

Please answer these questions accurately. Thank you

*What is your reason for visiting our practice?

*When was your last dental exam?

*When was your last dental cleaning?

Do your gums bleed when you brush or floss your teeth?

*How important are your teeth to you?

What are your dental goals?

Are you currently experiencing any dental pain or discomfort?

Do you have any sores or growths in your mouth?

*How many times per day do you brush your teeth?

*Do you floss and or use a WaterPik

*Have you ever had periodontal (gum) treatments like scaling and root planing?

Have you ever had a reaction to, or problem with, dental anesthesia?

*Have you ever seen a Periodontist (gum specialist) before?

Have you ever been previously diagnosed with gum disease by a dentist?

*How often do you get your teeth cleaned?

Do you clench or grind your teeth?

Is there a FAMILY history of

Periodontal (Gum) Disease

Heart Disease

Type 1 or Type 2 Diabetes

Cancer

Health History Cont.
Please check/answer all that apply:

*What is your current weight (lbs)?

What is your current height (inches)?

*Are you in good physical health?

Date of last physical exam?

*Are you currently being seen or treated by a physician?

*Have you had a serious illness, operation or been hospitalized in the past 5 years?

*Heart murmur/rhythm disorder

*High or low blood pressure

*Heart attack(s)

*Cardiac pacemaker

*Have you had any type (either total or partial) of joint replacement surgery (hip, knee, shoulder)?

*Have you had a heart valve replacement or heart surgery?

*Asthma

*Artificial (prosthetic) heart valve

*Previous Infective endocarditis

*Congenital heart disease (CHD)

*Coronary artery disease (CAD)

*Tuberculosis

*Emphysema

*Do you smoke cigarettes?

*Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?

*Do you use any other forms of tobacco or nicotine products (cigars, snuff, chew)

*Blood transfusion

*Anemia

*Congestive heart failure

*Atrial fibrillation

*Bronchitis

*Sinus trouble

*Hemophilia

*AIDS or HIV infection

Have you had or do you currently have...

*Anxiety

*Epilepsy

*Mental health disorders

*Thyroid trouble

*Type 1 Diabetes

*Type II Diabetes

*Kidney trouble

*Neurological disorders

*Lupus

*Arthritis

*Osteoporosis/ osteopenia

*Gastrointestinal disease

*Stomach ulcers

*G.E. reflux/persistent heartburn (GERD)

*Sexually transmitted disease

*Immune deficiency

*Rheumatoid arthritis

*Cancer, radiation therapy or chemotherapy

*Chronic pain

*Glaucoma

*Depression

Social History

*Do you use vaping (E-cig) products?

History of drug abuse?

*How many alcoholic beverages do you have per week?

History of alcohol abuse?

Do you consume a well balanced diet?

Pregnancy (Women Only)

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Medications Allergies
Medications (Are you now taking...)

Are you taking any blood thinners? (Coumadin, Plavix, Eliquis, Xarelto, Pradaxa, Aspirin)

Are you taking hormonal replacements?

Are you taking any medication to treat osteoporosis (such as Fosamax, Actonel, Boniva, Reclast, Prolia)?

Are you taking, or scheduled to take, an IV medication to treat bone pain, hypercalcemia, multiple myeloma or metastatic cancer?

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone

Suboxone

Oxycodone

Fentanyl

Other

Other Description

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

NSAIDs (Ibuprofen)

Aspirin

Amoxicillin

Codeine or other narcotics

Latex

Iodine

Metals

Do you have any known allergies?

Please list any allergies other than drug allergies?

Are you taking any kind of medication, drug, pills?

Please list any other medications or antibiotics you are allergic to.

Medication / Antibiotic Allergy #1

Medication Name

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

FEES & PAYMENTS

We accept Visa, Mastercard, Discover, cash or check. We do offer third party financing to patients through Care Credit. Depending on your credit score, different options are available . Please let us know if you are interested in Care Credit. Bear Canyon Periodontics is a unrestricted provider which gives us the freedom to work with just about all dental insurances. We accept ALL insurance policies that have both in network and out of network coverage. However, it is the patient's responsibility to research and be familiar with their policy and benefits. Dental insurance is a contract between you and your insurance company. We will do everything possible to assist you in the process. We will file all insurance claims as a courtesy so please provide us with accurate and complete insurance information. While we will submit claims to your insurance on your behalf, we are not privy to their decision making and we will direct you to contact your insurance company if you have any questions or concerns about insurance coverage. We require a deposit to schedule a surgical and non-surgical (deep cleaning) procedure. These procedures are long appointments that we reserve for you and for only you. We do not double book. Payment in full/co-payments/deductible(s) are due at the time of service. Refunds/overpayments are mailed by check to your address on file within 30 days of a credit being generated on your account. Any returned refund checks and or bounced checks are subject to a $5 reprocessing fee. Failure to pay your account balance in full will result in turning your balance over to an outside collection agency.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Release of Information

This signature on file is my authorization for the release of information necessary to process my claim.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Cancellation Policy

I understand I have a minimum of 48 hours prior to my appointment to notify us of changes or cancellations. If I fail to do so, I am subject to a late cancellation fee of $150. Appointments scheduled for a Monday will need to be cancelled/rescheduled by 5:00pm the Wednesday prior. For a late cancellation of a surgical appointment with less than 72 hours (3 business days) notice, I will forfeit the 50% deposit that was paid to reserve my appointment.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

OFFICE COMMUNICATION/APPOINTMENT REMINDERS

I give my consent to receive text messages (SMS) for appointment reminders. As part of our normal patient confirmation process, patients will receive several text messages, emails and or phone calls to confirm their appointments. I am required to respond to appointment confirmation attempts via email, text message and phone calls. If I do not respond to confirmation attempts, we will be under the assumption that you will not be attending your appointment and your appointment may be cancelled without notice.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Authorization for Service

I authorize my Periodontist and his designated staff, to perform an oral and periodontal examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays and photographs required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages and texts to be left on my phone and / or mobile phone concerning my appointment.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Notice of Privacy Practices

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.