NEW PATIENT FORM Print Form
PATIENT INFORMATION
Date of Birth: 
Send appointment reminders via: Text Email Mail
Was our website a factor in your decision to visit our practice? Yes No
EMERGENCY CONTACT
PERSON RESPONSIBLE FOR ACCOUNT
Date of Birth: 
INSURANCE INFORMATION
Primary Insurance
Date of Birth: 
Secondary Insurance
Date of Birth: 
Authorization

All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Dr. Cannon to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to Dr. Cannon. I permit a copy of this authorization to be used in place of the original. I give Dr. Cannon, its employees, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.

Date: 
PAYMENT
Does the person responsible for the account already have an account with this office?  Yes No
PAYMENT POLICIES
Thank you for taking the time to understand our payment policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our office staff for clarification.
For Patients with Dental Insurance

We accept dental insurance assignments, with the understanding that any uninsured portion not covered by your insurance plan is to be paid by you at the time of service. As a courtesy, our office will file all applicable insurance forms. Please note that although we strive to provide accurate information, such information is not a guarantee of payment or eligibility with your insurance company and is only an estimate. Your dental insurance plan is a contract between you, your employer, and the insurance company. Depending on your specific insurance plan, your dental insurance may not fully cover our office dental fees for the services we render. The difference between our office dental fees and your insurance reimbursement is your responsibility.

Returned Checks
Personal checks that are returned due to "insufficient funds" are subject to a .00 service fee.
SERVICE CHARGE

Payment is due at each appointment. I agree to pay any outstanding insurance balance within 30 days of the monthly billing date. Please be advised that there is a "Broken Appointment fee" for any missed or broken appointment without 48 hour notice that ranges from .00 to 0.00 dependent on the appointment time block and a minimum of 72 hour notice for Monday appointments. To serve all of our patients in a timely manner, we may need to reschedule an appointment if the patient is 15 minutes or more late in arriving to our practice. A "Broken appointment fee" will be assessed. To avoid this charge, kindly give us a minimum of 48 hour notice for any appointment cancellation. Feel free to contact us at any time with questions you may have.

Date: 
X-Ray/Records Release
There is a fee of .00 for any release of X-rays and/or records.
Minors

Adult patients are responsible for full payment at time of service. The adult accompanying a minor is responsible for payment. This office will not bill a non-custodial parent for services delivered to a minor. For unaccompanied minors, treatment may be denied unless charges have been pre-approved to a credit card or other payment arrangements have been made.

Authorization

I hereby authorize payment directly to Dr. Brown of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of the above-named patient's dental treatment. The information on the page and the dental/medical histories are correct to the best of my knowledge. I grant the right to Dr. Brown to release the patient's dental and/or medical histories and other information about the patient's dental treatment to third-party payers and/or other health professionals.

Date: 
DENTAL HISTORY
PREVIOUS DENTIST
LAST DENTAL VISIT
Last dental visit:
Treatment Complete? Yes No

Last X-Rays:
Last Full-Mouth X-Rays: 
Last Cleaning: 
DENTAL HYGIENE
Are you interested in regular hygiene cleanings? Yes No
TODAY'S VISIT
What is the main reason for your visit today?:
Tooth Pain
Check Up
Cleaning
Whitening
Cosmetic Dentistry
Restorative Dentistry
What would you like to learn more about?
Whitening
Cosmetic Dentistry
Implants
Bridges
Veneers
Dentures
Partial Denture
Prevention
DENTAL CONCERNS
Check all that apply.
Teeth
Broken/Chipped
Crooked
Decay
Difficulty Chewing
Discolored
Loose/Missing Filling
Loose Teeth
Tooth Pain
Food Trap Areas
Grinding or Clenching
Missing Teeth
Mouth Sores
Sensitive to Cold
Sensitive to Heat
Sensitive to Biting
Sensitive to Sweets
Blisters on Lips/Mouth
Orthodontic Treatment
Bad Taste in Mouth
Gums
Bad Breath
Red (Discolored)
Abcessed
Bleeding
Sore
Swollen
Receding
Periodontal Treatment
Facial/Jaw Pain
Frequent Headaches
Avoid Certain Foods
Popping/Clicking
Pain in Temples
Jaw Locks Open/Closed
Jaw Injury
Head Injury
Neck Injury
Pain Around Ear
TMJ Pain
Other Concerns
Smoking/Dipping
Biting Cheeks or Lip
Fillings
Wisdom Teeth
Nail Biting
Sleep Apnea
Limited Orthodontics
Burning Tongue
Tooth Replacement
Fractured Tooth Syndrome
CPAP
Implants
Stain
Chew on One Side
Snoring
Teeth Straightening
Retainer
Dry Mouth
Wisdom Teeth Extraction
Cosmetics
Smile Makeover
Dental Phobias
HAVE YOU EVER HAD:
Check all that apply.
Orthodontic Treatment
Oral Surgery
Periodontal Treatment
A Bite Plate or Mouth Guard
Any canker sores or cold sores on your lips, tonge, gums, or body
RATINGS
On a scale of 1-5 (1 bad, 5 good), please rate how you feel your overall dental health is.
On a scale of 1-5 (1 bad, 5 faithful), over the last ten years, rate how faithfully you have had your teeth cleaned.
On a scale of 1-5 (1 not sensitive, 5 very sensitive), what is your level of sensitivity to dental procedures?
On a scale of 1-5 (1 not sensitive, 5 very sensitive), what is your sensitivity to dental cleaning appointments?
On a scale of 1-5 (1 unhappy, 5 very happy), rate how you feel about the look of your smile.
On a scale of 1-5 (1 poor, 5 great), how do you rate your quality of sleep?
On a scale of 1-5 (1 being low, 5 being high), if you snore, how would you rate the severity of your snoring?
MISCELLANEOUS
Has fear ever been an issue for you in a dental office? YesNo
Has time ever been a factor in getting your dental work done? YesNo
Has the cost of denal treatment been a concern for you? YesNo
MEDICAL HISTORY
How is your general health? Good Fair Poor
Last visit:
Do we have permission to contact your doctor regarding your care? YesNo
HAVE YOU EVER HAD:
Check all that apply.
Arthritis
Arteriosclerosis
Birth Defects
Cancer/Chemotherapy
Emotional Problems
Head Injury
Heart Murmur/Trouble
History of Substance Abuse/Drug Addiction
Kidney Problems
Numbness of arms or hands
Swollen/Painful joints
Allergies
Asthma
Blood Disease
Diabetes
Endocrine Problems
Intestinal Disorders
Hepatitis A, B, or C
Hypertension (High blood pressure)
Liver Problems
Pneumonia
Shortness of Breath
Anemia
Bruise Easily
Dizziness
Epilepsy
Seizures
Fainting
Hearing Disorders
High/Low Blood Sugar
Hypotension (Low blood pressure)
Nervous Disorder
Rheumatic Fever
Heart Attack/Stroke
Heart Surgery
Pacemaker
Artificial Valves
Congenital Heart Defect
Mitral Valve Prolapse
Artifical Bones/Joints
Shingles
HIV/AIDS
Blood Transfusion
Fever Blisters
Sinus Problems
Severe/Frequent Headaches
Radiation Treatments
Psychiatric Problems
Tuberculosis
Venereal Disease
Hemophilia
Abnormal Bleeding
Ulcers
Difficulty Breathing
Hospitalized for any reason
Emphysema
Glaucoma
Thyroid Disease
Angina
Artificial Hip/Joint
Gout
Chest Pain
Circulatory Problems
Congenital Heart Lesion
Cortisone Medicine
Convulsions
Herpes
Leukemia
Excessive Thirst
Hay fever
Heart disease
Hives/skin rash
Hypoglycemia
Irregular heartbeat
Lung disease
Osteoporosis
Pain in jaw joints
Parathyroid disease
Recent weight loss
Rheumatism
Scarlet fever
Sexually transmitted disease
Sickle cell anemia
Sinus trouble
Tattoos/body piercing
TMD/TMJ (jaw pain)
X-ray or cobalt treatment
Yellow jaundice
Chronic fatigue syndrome
Cough-persistent or bloody
Latex sensitivity
Smoker
Swelling of feet/ankles
Swollen neck glands
Tonsillitis
Tumor or growth on head/neck
Easily winded
Anaphylaxis
Alzheimer's disease
Frequent diarrhea
Genital herpes
Renal dialysis
Spina bifida
HAVE YOU EVER HAD AN ADVERS REACTION OR ALLERGIES TO ANY MEDICATION OR SUBSTANCE?
Check all that apply.
Acrylic
Asprin
Barbiturates
Codeine
Dental Anesthetics
Erythromycin
Iodine
Latex
Metals
Nitrous Oxide
Novocaine
Penicillin
Sedatives
Sulfa Drugs
Tetracycline
Valium
Xylocaine
Are you currently taking or have you ever taken any bisphosphonate drugs? These include: alendronate (Fosamax), clodronate (Ostac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), tiludronate (Skelid), zoledronic acid (Zometa). YesNo
Do you take or have you taken Phen-Fen or Redux? YesNo
Do you smoke or chew tobacco? YesNo
Do you use alcohol, cocaine, or other drugs? YesNo
Do you wear contact lenses? YesNo
Are you on a special diet? YesNo
Have you lost or gained more than 10 pounds in the past year? YesNo
Do you use more than two pillows to sleep? YesNo
Have you ever had any excessive bleeding requiring special treatment? YesNo
Have you been treated in a hospital in the last five years? YesNo
Do you wish to talk to the dentist privately about any problems/concerns? YesNo

All of the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.

Date: 
We can look at your mouth from 3 different perspectives. This will help us determine how to best treat you and your specific dental needs. What combination of these would you like us to use for your situation?
At what point do you want us to initiate treatment for you?
HIPAA PRACTICES OF ACKNOWLEDGEMENT

We are required by the Health Insurance Portability and Accountability Act (HIPAA) to both offer our patients a copy of our Notice of Privacy Practices and to obtain your signature that we did offer you this document.

A copy of our Notice of Privacy Practices is available to you and is displayed at all times in our reception area.

This acknowledgement will be kept in your dental file. If you would like a copy, please feel free to request one at any time.

Thank you.

Date: 
FINANCIAL AND DENTAL INSURANCE POLICY

We are committed to providing you with the best possible dental care. If you have medical and dental insurance, we will gladly help you receive your maximum allowable benefits, thus minimizing your costs. In order to achieve these goals, we need your assistance and understanding of our policy.

Payment for services is due at the time they are rendered unless payment arrangements have been made in advance in written form. We accept cash, check, Visa, MasterCard, Discover, American Express, CareCredit and Springstone. In order to keep our operating costs and ultimately your costs down, we generally do not bill patients. As a courtesy to you, we will file your insurance claim for you. In order to process your claim, we just have complete insurance information.

Returned checks will be charged a .00 fee upon notification to us by the bank, and we may require alternative means of future payments. You are responsible for all reasonable collection cost and attorney fees in the event of any default of balance owed.

When you make an appointment with us, please remember that this time has been reserved for you. A charge of .00 will be made for every half hour of your scheduled appointment time for broken or cancelled appointments without 48 hours notice.

We will gladly discuss your proposed treatment and answer any questions relating to your account. We will not perform any procedure without your knowing the cost of the treatment up front.

As far as your insurance is concerned, please understand the following:

  1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
  2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are usually covered up to the allowance determined by each carrier. This does not apply to companies who reimburse based on an arbitrary "schedule of fees" which bears no relationship to the current standard and cost of care in this area.
  3. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We do not render our services on the basis that insurance companies will accept or pay all of our fees. Proposed treatment plans are based on services needed.
  4. Estimate of co-pays are based on information available at that time. Insurance carriers do not guarantee benefits until claim is processed.
  5. If your insurance fails to pay the portion which they are supposed to cover, you are ultimately responsible for the balance due.

WE must emphasize that as dental care providers, our relationship is with YOU, not your insurance company. While the filing of insurance is a courtesy that we extend to our patients. ALL charges are your responsibility from the date services are rendered. If questions or concerns arise, we encourage you to contact us promptly for assistance in the management of your account.

If you have any questions about the above information or uncertainty regarding insurance coverage, please do not hesitate to ask us.
We are here to help you.

Sincerely,
Russell W. Cannon and Staff

I HAVE READ THE ABOVE CONDITIONS AND AGREE TO THEIR CONTENT.

Date: 
QUESTIONNAIRE FOR SNORING
Epworth Sleepiness Scale Form

How likely are you to doze off or fall asleep in the situations described in the box below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you.


Use the following scale to choose the most appropriate number for each situation:

  • 0= Would never doze
  • 1= Slight chance of dozing
  • 2= Moderate chance of dozing
  • 3= High chance of dozing
Situation
Chance of Dozing
Sitting and Reading
Watching T.V.
Sitting, inactive in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without Alcohol
In a car, while stopped for a few minutes in traffic
Total Score
Behavior During Sleep

Use the following scale to choose the most appropriate number for each situation:

  • 0= Never during a usual night
  • 1= Less than once a week
  • 2= Once to about half the nights per week
  • 3= Half the nights to almost always
  • 4= Almost always or every night
  • ?= Don’t know or haven’ been told
During your usual sleep, you have noticed or have been told, you do the following:
Snore Loudly
Stop Breathing
Choke, struggle for breath
Toss and turn frequently
Wake up with headache
Usual number hours of sleep per night
Number of time you rise to use toilet
Have you had an overnight sleep test
YesNo
Date: 
Medical Insurance Name: (Choose one)
Local Anesthetic Consent Form

Our office routinely uses local anesthetics to aid in the administration of quality pain-free dental care. Although local anesthesia is extremely safe from a statistical standpoint, complications from the administration of local anesthetic are possible.

Potential common complications include, but are not limited to, pain, swelling and bruising. Rare but more serious potential complications include, but are not limited to, permanent numbness or abnormal sensation as well as life-threatening reactions.

By signing this consent, patient understands the provisions of informed consent as described and has no further questions.

Date: 
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