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Our Team’s Mission at Omni Dental is to effectively communicate with our patients in order to understand their wishes and desires and to provide ongoing education to optimize their overall health and well being. We will then offer extraordinary, comprehensive dental care in a professional environment which meets the diverse, individualized needs of our patients.
Patient Information
Date of Birth___________________________ Name______________________________________________________________________ Preferred Name______________________________ (Last) (First) (MI) Address_________________________________________________________ City______________________ State________ Zip_____________ Home phone__________________________ Cell phone__________________________ E-mail_________________________________________ How did you hear about our office? ____________________________________________________________________________________ Check Appropriate Boxes: If Student, Name of School/College_____________________________________ City______________________ State________
Patient or Parent/Guardian’s Employer___________________________________________________ Work phone__________________________
Business Address__________________________________________________ City______________________ State_________ Zip___________
Spouse or Parent/Guardian’s Name_____________________________ Employer___________________________ Work Phone_______________
Person to Contact in Case of Emergency_____________________________________________________________ Phone__________________
Responsible Party (if other than above)

Name of Person Responsible for this Account________________________________________________ To Patient_________________________ Address__________________________________________________________ City_______________________ State______ Zip_____________ Home phone__________________________ Cell phone__________________________ E-mail_________________________________________ Driver’s License #_________________________________ Date of Birth________________________ SS#/SIN____________________________ Employer____________________________________________________________________________ Work Phone________________________ Is this Person Currently a Patient in our Office?
Insurance Information
Name of Insured_________________________________________________________________________ To Patient_______________________ Date of Birth____________________________________________________ SS#/SIN________________________________________________ Name of Employer________________________________________________ Union or Local #_________________ Work Phone______________ Address of Employer____________________________________________________ City______________________ State_____ Zip___________ Dental Insurance Company_____________________________________________________ Group #______________ Policy/ID #_____________ DO YOU HAVE ANY ADDITIONAL INSURANCE? Name of Insured_______________________________________________________________________ To Patient_________________________ Date of Birth_____________________________________________________ SS#/SIN_______________________________________________ Name of Employer_________________________________________________ Union or Local #_________________ Work Phone_____________ Address of Employer____________________________________________________ City______________________ State_____ Zip___________ Dental Insurance Company_____________________________________________________ Group #______________ Policy/ID #_____________ Please continue with update on reverse side of form. Medical History

Name______________________________________________________________________ Preferred Name:____________________________
(Last) (First) (MI)
Physician____________________________ Office Phone________________________ Date of Last Medical Exam____________
1. Are you under medical treatment now?……………………… 9. Are you allergic to or have you had any reactions to the 2. Have you ever been hospitalized for any surgical following?………………………………………………………. operation or serious illness within the last 5 years?………. Local Anesthetics (e.g. Novocain)…………………………… If yes, please explain_____________________________ Penicillin or other Antibiotics…………………………………. _______________________________________________ Sulfa Drugs……………………………………………………. 3. Do you take any medications for prevention of Barbiturates……………………………………………………. Osteoporosis? (Fosamax, Boniva, etc.)……………………. Sedatives………………………………………………………. 4. Have you had any joint replacements?. Iodine……………………………………………………………. If yes, which joint and when?________________________ Aspirin…………………………………………………………. 5. Do you have a persistent cough or throat clearing not Any Metals (e.g. nickel, mercury, etc.)………………………. associated with a known illness (last more than 3 weeks)?. Latex Rubber…………………………………………………… 6. Have you ever taken Fen-Phen/Redux?……………………. Other including any foods (please list)________________ 7. Do you use tobacco?…………………………………………. 8. Do you use or have you used controlled substances?……. a) Are you pregnant or think you may be pregnant?………. b) Are you nursing?……………………………………………. c) Are you taking oral contraceptives?………………………. Please list all medications you are currently taking including non-prescription: _____________________________________________ Do you have or have you had any of the following? Heart Disease………………………… Asthma……………………….….……. Heart Attack…………………….……. Cancer………………………….……. Fainting…………………….…………. Low Blood Pressure……….………… Rheumatic Fever…….………………. Chemotherapy………………….……. Epilepsy / Convulsions…….….……. Mitral Valve Prolapse………….……. Leukemia……………………………… Thyroid Problem……………………… Heart Murmur………….……………. Anemia………………………….……. Emphysema………………….………. AIDS or HIV Infection………………. Arthritis……………………….….……. Diabetes……………………….……… Angina / Chest Pain…….…………… Stroke…………………………………. Hepatitis……………………….……. Hay Fever / Allergies………………… Swollen Ankles………………………. Recent Weight Loss…………………. Easily Winded………………………… Glaucoma…………………….……. Respiratory Problems…….…………. Tuberculosis………………………….
Dental History
Name of Previous Dentist and Location_______________________________________ Date of Last Exam_____________
Please state any dental concerns you have: _____________________________________________________________________
_________________________________________________________________________________________________________
1. Do your gums bleed while brushing or flossing?…………. 8. Do you have frequent headaches?………………………. 2. Are your teeth sensitive to hot or cold liquids/foods?……. 9. Do you clench or grind your teeth?………………………. 3. Are your teeth sensitive to sweet or sour liquids/foods?…. 10. Do you bite your lips or cheeks frequently?……….……. 4. Do you feel pain to any of your teeth?……………………… 11. Have you ever had any difficult extractions in the 5. Do you have any sores or lumps in or near your mouth?… past? Oral surgery?………………………………………… 6. Have you had any head, neck or jaw injuries?….………… 12. Have you ever had any prolonged bleeding following 7. Have you ever experienced any of the following extractions?…………………………………………………. 13. Have you had any orthodontic treatment?………………. Clicking?…………………………………………….…. 14. Do you wear dentures or partials?………………………… Pain (joint, ear, side of face)?………………………… If yes, date of placement_________________________ Difficulty in opening or closing?……………………… 15. Have you ever received oral hygiene instructions Difficulty in chewing?…………………………………… regarding the care of your teeth and gums?…….……. 17. Would you like to change anything?………………………. Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to
release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the
period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay
directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may
pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
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Signature of Patient (or parent/guardian if minor) Date
Omni Dental
Personal Smile Evaluation
Are you happy with the color of your teeth? Yes  No  Would you like for your teeth to be whiter? Would you like your teeth to be straighter? Do you have spaces between your teeth that you would like closed? Yes  No  If Yes, where? Do you have missing teeth that you would like to replace? Yes  No  Explain: Do you have old silver fillings that you would like to replace with tooth-colored fillings? 10. If you could change anything about your smile, what would you change? Omni Dental Financial Guidelines
Our aim is to provide each patient with quality, comprehensive dental care in a professional environment which meets the
diverse needs of our patients. Our dental office is a business that must be managed efficiently if we are to continue serving
our community with quality aesthetic, restorative, and preventive dentistry. Our fees are fair and reflect the care and
expertise with which we treat each patient.
To keep our fees from rising considerably and to minimize the expenses of billing and bookkeeping, we offer patients
payment options. We ask that all accounts be paid in order to reserve an appointment unless other arrangements
have been made with the financial office.

INSURANCE
Insurance claims will be processed through our business office on a company-by-company basis. Patients with insurance
are responsible for the entire fee prior to treatment, unless our practice accepts assignment of benefits from your particular
company. In this case the patient is responsible for his or her estimated portion of the fee prior to treatment.
PAYMENT METHODS
Cash:
This includes money orders, personal checks and cashier checks Cards accepted include MasterCard, Visa, American Express, and Discover. Healthcare Financing: If you need extended payments, we have excellent options. Care Credit and Citi Health are lines of healthcare credit, which allow you to pay as little as 3% of your balance per month. The initial charge amount may have an interest free period. Please ask a staff member for details. Once approved, the monthly payments are made to our Healthcare Financing Partner. We have convenient office hours to serve our patients and we reserve appointment time exclusively for each patient. We will work with you to schedule times that maximize your care in the shortest number of appointments. When we reserve an appointment for a patient, the focus of the doctor and the hygienist is only on that patient’s care and the time allowed is very important. Each appointment in a patient’s treatment schedule moves them closer to completing their needed dentistry. We ask for a 48 hour notice if you are unable to keep a scheduled appointment time. Our main purpose for having guidelines is to keep our patients informed of their choices and obligations. We want to serve your dental needs and handle the business aspect through a clear understanding by all parties involved. If you have any questions, please contact us in person or by telephone. Each patient will receive a treatment plan with the fees and choices for payment options. I understand and have read all of the information on this form. I understand and agree that I am responsible for all treatment fees on my account. I understand that if my insurance does not pay for any treatment or pays less than anticipated, I am responsible for the entire balance. ______________________________________________________________________________________ Print
Patient HIPAA Consent Form
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: o Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly o Obtain payment from third-party payers o Conduct normal healthcare operations such as quality assessments and physician certifications I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care 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. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name: ________________________ Signature: ________________________ Relationship to Patient: ________________________ Date: _____________ Staying within the “reasonable” guidelines of HIPAA, I give permission for Omni Dental to discuss my dental care and related issues with the following persons, in addition to myself. If none, please state so: Name: Relationship: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.tricitydental.net/docs/omni-patient-forms.pdf