HowDidYouHearAboutUs?⃝Referral(whomaywethank):___________________________
⃝InternetSearch⃝Other:_____________________________
⃝Female
Patient’sName:_________________________________BirthDate:____|_____|________ ⃝Male
Address:_________________________________________________________________
City:___________________________State:______ZipCode:___________⃝Single⃝Married⃝Widowed
Home#:_____________________Work#:_____________________Cell#:__________________________
PatientSSN:_______--_______--_________EmailAddress:_______________________________________
DoYouLiveorWorkInTheGulch?⃝Yes⃝No
Employedby/Studentat(circleone):_____________________________________________________
PersonresponsibleforthisAcct:___________________SSNofResponsibleParty:__________________
EmergencyContact:______________________________Phone:_________________Relation:________________
CHECKALLTHATAPPLYTOYOU:
Diabetes
⃝Yes⃝No
InfectiveEndocarditis
⃝Yes⃝No
CongenitalHeartCondition
⃝Yes⃝No
ArtificialJoint ⃝Yes⃝No
ArtificialHeartValve
⃝Yes⃝No
HeartMurmur ⃝Yes⃝No
HighBloodPressure
⃝Yes⃝No
RheumaticFever ⃝Yes⃝No
LiverDisease
⃝Yes⃝No
AbnormalHeartCondition
⃝Yes⃝No
BloodDisease ⃝Yes⃝No
AIDS/HIV
⃝Yes⃝No
KidneyDisease ⃝Yes⃝No
Pregnant/nursing
⃝Yes⃝No
OralContraception
⃝Yes⃝No
Stroke ⃝Yes⃝No
Pacemaker
⃝Yes⃝No
Stent ⃝Yes⃝No
Tuberculosis
⃝Yes⃝No
Hepatitis:A,B,C,D
⃝Yes⃝No
Jaundice
⃝Yes⃝No
RespiratoryProblems
⃝Yes⃝No
Emphysema
⃝Yes⃝No
Asthma ⃝Yes⃝No
COPD ⃝Yes⃝No
SinusProblems ⃝Yes⃝No
HayFever
⃝Yes⃝No
CHECKALLTHATAPPLYTOYOU:
BloodTransfusion
⃝Yes⃝No
Lupus ⃝Yes⃝No
Sjogren’sSyndrome
⃝Yes⃝No
Glaucoma
⃝Yes⃝No
BloodDisorders ⃝Yes⃝No
AbnormalBleeding
⃝Yes⃝No
Anemia ⃝Yes⃝No
Fainting ⃝Yes⃝No
Dizziness
⃝Yes⃝No
Seizures
⃝Yes⃝No
Epilepsy
⃝Yes⃝No
NervousDisorders
⃝Yes⃝No
MentalDisorders
⃝Yes⃝No
VenerealDisease
⃝Yes⃝No
RecurrentIllness ⃝Yes⃝No
SlowHealing/MouthSores
⃝Yes⃝No
Osteoporosis
⃝Yes⃝No
Osteopenia
⃝Yes⃝No
Cancer ⃝Yes⃝No
Chemotherapy ⃝Yes⃝No
RadiationTherapy
⃝Yes⃝No
DrinkAlcohol?
⃝Yes⃝No
_______drinks/week
Tobacco
⃝Yes⃝No
____CigarettePacks/week
____SmokelessCans/week
DOYOUHAVEAHISTORYOF:
AcidReflux Vomiting
⃝Yes⃝No
⃝Yes⃝No
HeartBurn
MorningSickness
22411thAvenueSouth,Nashville,TN37203
(615)334-0184--GulchDentalStudio.com
⃝Yes⃝No
⃝Yes⃝No
PLEASELISTALLCURRENTMEDICATIONS:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
HaveYouEverBeenTreatedforPeriodontalDisease?(e.g.gumdisease,periodontitis) ⃝Yes⃝No
HaveYouEverHadReplacementSurgery?(e.g.Hip,Knee,etc)
⃝Yes⃝No
HaveYouPreviouslyTakenAntibioticPre-MedicationsBeforeDentalProcedures?
⃝Yes⃝No
NameOfPreviousDentist:_______________________________Phone:_________________________________
MayWeRequestYourDentalRecords&X-rays?
⃝Yes⃝No
DateOfLastBitewingX-rays:______|_______|_______DateOfLastPanoramicX-ray:______|______|______
AREYOUALLERGICTOOREXPERIENCEDAREACTIONTOTHEFOLLOWING?
LocalAnesthetic(e.g.Novocaine) ⃝Yes⃝No Penicillin/OtherAntibiotic
⃝Yes⃝No
Latex ⃝Yes⃝No Aspirin/Codeine ⃝Yes⃝No
Barbiturates/Sedatives ⃝Yes⃝No SleepingPills
⃝Yes⃝No
SulfaDrugs
⃝Yes⃝No OtherAllergies ⃝Yes⃝No
PleaseListOtherKnownAllergies_________________________________________________
_________________________________________________
_________________________________________________
AREYOUHAPPYWITHYOURSMILE?
Wouldyouliketodiscussanythinginparticular
withDr.TrembleyorDr.Newmanconcerning
yoursmile? ⃝Yes⃝No
Areyouhappywithyoursmile?
⃝Yes⃝No
CHECKALLTHATAPPLY:
AreYouInterestedInBotoxTherapy⃝Yes⃝No
In-OfficeTeethWhitening ⃝Yes⃝No
TMJTherapy
⃝Yes⃝No
ACosmeticConsultation ⃝Yes⃝No
DoYouExperienceToothSensitivity⃝Yes⃝No
Welovetoknowaboutourpatients.Sharesomethinginterestingaboutyourselfbelow!
22411thAvenueSouth,Nashville,TN37203
(615)334-0184--GulchDentalStudio.com
DENTAL INSURANCE INFORMATION (Please DO NOT list your Medical Insurance)
PRIMARYINSURANCE
NameofInsured:(First)__________________________(Last)_______________________________(MI)_______
Insured’sBirthDate:______|______|________ID#:______________________Group#:___________________
Insured’sSocialSecurity#:________--_______--________Insured’sEmployer:__________________________
Patient’sRelationshiptoInsured: ⃝Self⃝Spouse⃝Child⃝Other:_____________________________
InsurancePlanName:___________________________________________________________________________
InsurancePlanAddress:_________________________________________________________________________
InsurancePlanPhone#:_________________________
SECONDARYINSURANCE
NameofInsured:(First)__________________________(Last)_______________________________(MI)_______
Insured’sBirthDate:______|______|________ID#:______________________Group#:___________________
Insured’sSocialSecurity#:________--_______--________Insured’sEmployer:__________________________
Patient’sRelationshiptoInsured: ⃝Self⃝Spouse⃝Child⃝Other:_____________________________
InsurancePlanName:___________________________________________________________________________
InsurancePlanAddress:_________________________________________________________________________
InsurancePlanPhone#:_________________________
TOTHEBESTOFMYKNOWLEDGE,ALLOFTHEPRECEDINGANSWERSARETRUEANDCORRECT
X:___________________________________________Date:_____|_____|_________
(SignatureofPatientorGuardian)
22411thAvenueSouth,Nashville,TN37203
(615)334-0184--GulchDentalStudio.com
OUR FINANCIAL POLICY
Allpatientswithoutdentalinsurancewillberequiredtopayforservicesatthetimeservicesare
rendered.Weacceptcash,personalchecks,andforyourconvenienceMasterCard,VisaandDiscover.
Forallpatientswithdentalinsurance,wewillprocessyourinsuranceclaimforyourreimbursementas
longaswehavecompleteinsuranceinformation.
Pleasekeepinmindyourinsurancepolicyisacontractbetweenyou,youremployerandtheinsurance
company.WeareNOTapartytothatcontract.Ourfinancialrelationshipiswithyou,notyour
insurancecompany.Allchargesareyourresponsibilitywhetheryourinsurancecompanypaysornot.
Pleasebeawarethatnotallservicesarecoveredbenefitsinalldentalcontracts.Youareresponsiblefor
theknowledgeofcoverageofyourdentalpolicy.
Ifyourinsurancecompanydoesnotpaytowardyourclaimwithin45daysofdateofservice,wewill
requireyoupaythebalancedue.
Pleasenotethatifyouaregivenafinancialestimateofyourservicespriortoservicebeingrenderedthat
isONLYANESTIMATEofcharges.Itispossiblethatyourdentalinsurancemaypaylessthanormore
thanwasestimated.
Balancesolderthan60dayswillbesubjecttofinancechargesof1.5%permonthontheunpaidbalance
of18%annum.Returnedcheckswillhaveanadditionalfeeof$30.00addedtotheamountofthe
returnedcheck.
Intheeventthatyouraccountbecomespastdue,youagreetoberesponsibleforallcostsofcollection
includingreasonableattorneyfeesandcourtcosts
PatientName:_____________________________________________
PatientSignature:___________________________________________Date:_____|_____|_________
22411thAvenueSouth,Nashville,TN37203
(615)334-0184--GulchDentalStudio.com
CANCELLATION POLICY
Dr.ClintNewmanandDr.JeffTrembleyarecommittedtoyourhealth.Whenyoumissanappointment,
otherpatientsareunabletotakeyourplaceandaredelayedunnecessarily.Ifyouareunabletokeepan
appointment,weaskthatyoucancelatleast24hoursinadvance.Pleasecallassoonaspossiblesothat
anotherpatientcanbegivenyourappointment.
Our office tracks missed appointments. A “no show” or “late cancellation” is defined as missing or
reschedulinganappointmentwithoutgiving24hoursofadvancednotice.Therewillbea$75.00charge
for a missed appointment. Insurance will not cover charges for “no show” or “late cancellation” fees.
Thischargeisinadditiontoanyotherchargesyoumayhaveincurred.
Unfortunately, repeated missed appointments may result in a letter discharging the patient from the
practice.Dr.NewmanandDr.Trembleyunderstandthatemergencieswilloccurandconsiderationwill
bemadeformissedor“noshow”appointments.
Bysigningbelow,youstatethatyouhavebeennotifiedandunderstandthispolicy.
X:___________________________________________Date:_____|_____|_________
(SignatureofPatientorGuardian)
22411thAvenueSouth,Nashville,TN37203
(615)334-0184--GulchDentalStudio.com
PRIVACY PRACTICE POLICY
IhavereadandreviewedtheNoticeofPrivacyPracticesPolicy(effectiveonSeptember23,2013).I
acknowledgethatIamentitledtoreceiveamorecompletedescriptionoftheusesanddisclosuresofmy
healthinformationatmyrequest.IunderstandthatthisofficehastherighttochangeitsNoticeof
PrivacyPracticesfromtimetotimeandthatImaycontactthisofficeatanytimetoobtainacurrent
copyoftheNoticeofPrivatePractices.
PatientSignature:___________________________________________
PrintPatientName:___________________________________________Date:_____|_____|_______
22411thAvenueSouth,Nashville,TN37203
(615)334-0184--GulchDentalStudio.com