Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
New Patient Form
Please fill out all the information to the best of your knowledge. All answers will be
kept confidential. If you have any questions, please ask us, and we'll be happy to
assist you.
Date:
Patient #:
/
/
01
01
2017
02
02
2018
Title: First Name:
Middle Name:
Last Name:
I prefer to be called:
03
03
2019
04
04
2020
Mr.
Sex:
Age:
Date of Birth (mm/dd/yyyy): Marital Status:
Social
Driver's Licence State & #:
05Security
05#: 2021
Ms.
/
/
06
06
2022
Mrs.
M
01
01
2027
Minor
AL
07 Address:
07
2023
Home
Phone:
Work Phone:
Cell Phone:
E-mail
Dr.
F
02
AR
08
08
2024
- 02
-2026 - Single
03
03
2025
Married
AZ
09
09
2025
Home Address: 04
City:
State: ZIP Code:
04
2024
Long-Term Partner
CA
10
10
2026
05
05
2023
Divorced
CO
11
11
2027
AL
06
06 Name:
2022
Widowed
CT
12
12
Employment: Employer's
Employer's Phone:
Occupation:
AR
07
07
2021
SeparatedDC
13
AZ
08
08
2020
DE
14
None
Employer's Address:
City:
State:
CA ZIP Code:
09
09
2019
FL
15
Full-Time
CO
10
10
2018
GA
16
Part-Time
AL
CT
Student
(if a full-time student):
Grade:
11 Name2017
HI
17
RetiredStatus: 11 School
AR
DC
12
12
2016
IA
18
AZ
DE
Not a Student
13
2015
ID
Best places and times to contact you:
Send19
appointment remindersCA
via:
FL
Full-Time
14
2014
IL
20
❏ Text Message ❏ Email
❏ Mail
CO
GA
Part-Time
15
2013
IN
21
CT
Please tell us where you 16
heard about
HI
2012us (check all that apply):
KS
22
DC
❏ Friend or Relative 17
❏ Newspaper Ad 23
❏ Radio Ad
(name):
Ad
2011
KY ❏ TV IA
DE
❏ Ad in Mail ❏ Saw
❏
❏
ID
our
Office
Insurance
Company
Our
Website
18
2010
LA
24
FL
❏ Search Engine (Google,
❏
IL
etc.)
Other
Website:
19
2009
MA
25
GA
❏ Other:
IN
20
2008
MD
26
HI
KS
21 in2007
ME
Was our website a factor
your decision to visit our practice? ❍ Yes 27
❍ No
IA
KY
22 if a minor):
2006 Spouse/Parent's Employer: Spouse/Parent Work
28 Phone: MI
Name of Spouse (or Parent,
Spouse/Parent Cell Phone:
LA
23
2005
MN - ID
- 29
IL
MA
24
2004
MO
30
IN
Other family members treated by us:
Additional Comments:
MD
25
2003
MS
31
KS
ME
26
2002
MT
KY
MI
27
2001
NC
LA
MN
28
2000
ND
MA
MO
29
1999
NE
MD
MS
30
1998
NH
ME
MT
31
1997
NJ
MI
NC
1996
NM
MN
ND
1995
NV
MO
NE
1994
NY
MS
NH
1993
OH
MT
NJ
1992
OK
NC
NM
1991
OR
ND
NV
Page 1/16
1990
PA
NE
NY
1989
RI
NH
Patient Information
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Emergency Contact
This should be the nearest relative who does not live with the patient.
Title: First Name:
Last Name:
Mr.
Work Phone:
Ms. Mrs.
Emergency_Contact
Address:
Dr.
Home Phone:
Person Responsible for Account
Title:
First Name:
Middle Name:
Mr.
Ms. /
/
Mrs.
01 Phone:
01
2027 Work Phone:
Home
Dr.
02 - 02 - 2026
03
03
2025
Billing
04 Address:
04
2024
05
05
2023
06
06
2022
Employment:
Employer's
Name:
07
07
2021
08
08
2020
None
Employer's Address:
09
09
2019
Full-Time
10
10
2018
Part-Time
11
2017
Retired11
12
12
2016
13
2015
14
2014
15
2013
16
2012
17
2011
18
2010
19
2009
20
2008
21
2007
22
2006
23
2005
24
2004
25
2003
26
2002
27
2001
28
2000
29
1999
30
1998
31
1997
1996
1995
1994
Date of Birth (mm/dd/yyyy): Social Security #:
Cell Phone:
-
Relationship to Patient:
E-mail Address:
City:
State: ZIP Code:
AL
AR
Last Name:
Relationship to Patient:
AZ
CA
Driver's Licence State & #:
Holder of Dental Insurance
for Patient:
CO
CT
AL
No
DC
Cell Phone:
E-mail Address:
AR Yes:
Primary
Insurance
DE Policy
AZ
Yes: Secondary Insurance
Policy
FL
City:
State:
ZIP
Code:
CA
GA
CO
HI
AL
CT
IA
Employer's Phone:
Occupation:
AR
DCID
AZ
DE
IL
City:
State:
ZIP Code:
CA
FL
IN
CO
GA
KS
AL
CT
HI
KY
AR
DC
IA
LA
AZ
DE
ID
MA
CA
FL
IL
MD
CO
GA
IN
ME
CT
HI
KS
MI
DC
IA
KY
MN
DE
ID
LA
MO
FL
IL
MA
MS
GA
IN
MD
MT
HI
KS
ME
NC
IA
KY
MI
ND
ID
LA
MN
NE
IL
MA
MO
NH
IN
MD
MS
NJ
KS
ME
MT
NM
KY
MI
NC
NV
LA
MN
ND
NY
MA
MO
NE
OH
MD
MS
NH
OK
ME
MT
NJ
OR
MI
NC
NMPage 2/16
PA
MN
ND
NV
RI
MO
NE
NY
SC
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Insurance Information
Primary Insurance
Insurance Holder's Name:
Date of Birth (mm/dd/yyyy): Relationship to Patient:
/
Employer:
/
01
01
2027
Insurance Company Name:
Insurance Company Phone:
02
02
2026
03
03
2025
Insured's SSN:
Insurance
Address:
City:
State: ZIP Code:
04 Company's
04
2024
05
05
2023
AL
06
06
2022
Secondary Insurance
AR
07 of Birth
07 (mm/dd/yyyy):
2021
Insurance Holder's Name:
Date
Relationship to Patient:
Employer:
AZ
08 / 08 / 2020
CA
09
09
2019
01
01
2027
Member ID:
Group ID:
Insurance Company Name:
Insurance Company
Phone:
CO
10
10
2018
02
02
2026
CT
11
11
2017
03
03
2025
DC ZIP Code:
Insured's SSN:
Insurance
Address:
City:
State:
12
12
2016
04 Company's
04
2024
DE
13
2015
05
05
2023
FL
AL
14
2014
06
06
2022
Authorization
GA
AR
2013
07 to15
07
2021
All of the above information is correct
the best
of my knowledge. I authorize use of this form
on all my
HI
AZ
16
2012
08
08
2020
insurance submissions and I authorize the release of information to all my insurance companies.
I
IA
CA
17
2011
09
09
2019
understand that I am responsible for my bill. I authorize Pearl Smile Dental to act as my agent
IDin helping
CO
18
2010
10
10companies.
2018 I authorize payment to Pearl Smile Dental.
me to obtain payment from my insurance
I permit a
IL
CT
19
2009
11
11
2017
copy of this authorization to be used in place of the original. I give Pearl Smile Dental, its employees,
DC
20
2008
12 to contact
2016 me at any/all phone numbers, includingIN
and/or other agents express prior12
consent
cell numbers
KS
DE
21
2007
13
2015
(by phone call or text message) and email addresses, for the purpose of treatment, insurance,
KYor payment.
FL
22
14or print2006
2014
Signature (Type your name to sign electronically,
and sign):
Date (mm/dd/yyyy):
LA
23
2005
15
2013
/ GA /
MA
HI
24
2004
16
2012
01
01
2017
MD
Consent for Treatment
IA
25
2003
17
2011
02
02
ME 2018
Patient Name:
ID
26
2002
18
2010
03
03
2019
MI
27
2001
IL
19
2009
04
04
2020
MN
28
2000
IN and other
20
2008
I hereby authorize the doctor or designated
staff to take X-rays, study models, photographs,
05
05
2021
MO
29 doctor
1999
KS
21
2007
diagnostic aids deemed appropriate by the
to make a thorough diagnosis of the06dental06
needs
of the
MS 2022
30
1998
KY
22
2006
above-named patient.
07
07
2023
MT
LA
31
1997
23
2005
Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended
treatment
08
08
2024
NC
MA
1996
24 such
2004
mutually agreed upon by us and to employ
assistance as required to provide proper
care.
09
09
2025
ND
MD
1995
25
2003
I agree to the use of anesthetics, sedatives,
and other medications as necessary. I10
fully understand
10
2026
NE
ME
1994
26
2002
that using anesthetic agents embodies certain risks. I understand that I can ask for a complete
recital
of
11
11
2027
NH
MI
1993
27
2001
any possible complications.
12
12
NJ
MN
1992
28the above
2000 treatment policy.
I have read, understood, and agree to
13
NM
MO
1991
29or print1999
Signature (Type your name to sign electronically,
and sign):
Date (mm/dd/yyyy):
14
NV
MS
1990
30
1998
/ 15
/
NY
MT
1989
31
1997
01
01
2017
16
OH
NC
1988
1996
02
02
2018
17
OK
ND
1987
1995
03
03
2019
18
OR
NE
1986
1994
04
04
2020
19
PA
Page 3/16
NH 2021
1985
1993
05
05
20
RI
NJ
1984
1992
06
06
2022
21
Member ID:
Group ID:
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Payment
Does the person responsible for the account already have an account with this office? ❍ Yes
❍ No
Payment Method
Notice: Payment is due at the time of service unless alternative arrangements have been made in advance. Please choose a
method of payment below.
Payment in Full
❍ Cash
❍ Check
❍ Credit Card Type:
Credit Card Number:
Expiration:
Card Verification Code:
VISA/MC/Discover: 3-digit code printed on back
/ 2017
AmEx: 4-digit code printed on front
Visa
01
2018
Your credit card information is kept on file for outstanding account balances.
MasterCard
02
2019
Payment Plans
Discover
03
2020
Start treatment immediately and pay over time with low monthly payments.
AmEx
04
2021
No-Interest Payment Plans
❍ CareCredit
05
2022
Pay for treatment over 6 or 12 months with NO interest.
06
2023
As long as you pay the low minimum monthly payment each month when due,
07
2024
and the balance in full by the end of the promotional 6- or 12-month term, no
08
2025
interest will be charged on your purchase.
09
2026
Low-Interest Payment Plans
10
2027
Enjoy low monthly payments with the 24, 36, 48, or 60 month extended plans.
11
The 14.9% APR is lower than average credit cards and makes convenient, fixed,
12
and low minimum monthly payments possible. This option is available for
treatment fees of $1000.00 or more. ($5000.00 or more for the 60 month plan.)
If you choose this option, you can fill out a CareCredit application at our office.
Would you like to discuss our office's financial policy? ❍ Yes ❍ No
Page 4/16
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
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 $25.00 service fee.
Service Charge
Payment is due at each appointment. I agree to pay any outstanding insurance balance within 60 days. If I
do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be
added to the account for the current monthly billing period. The service charge will be a periodic rate of
1.5% per month (or a minimum charge of $2.50 for a minimum balance of $25.00) which is an annual
percentage rate of 18% applied to the last month's balance. In case of default of payment, I promise to
pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees
incurred to effect collection of this account balance or any future accounts. Please be advised that there is
a $50.00 fee charged for missed or broken appointments without 24 hours notice. To avoid this charge,
kindly give us a minimum of 24 hours notice for any appointment cancellation. Feel free to contact us at
any time with questions you may have.
X-Ray/Records Release
There is a fee of $25.00 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
Patient Name:
I hereby authorize payment directly to Pearl Smile Dental 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 Pearl Smile Dental 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.
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
/
Page 5/16
01
02
03
04
05
/
01
02
03
04
05
2017
2018
2019
2020
2021
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Dental History
Previous Dentist
Dentist Name:
Dental Practice Name:
Phone:
Address:
City:
State: ZIP Code:
AL
AR
AZ
CA
CO
Last Dental Visit
CT complete?
Last Dental Visit (m/y): What were you treated for?
Treatment
DC ❍ No
❍ Yes
/
DE
01
2027
What was done at your last dental visit?
Last X-Rays:
Last Full-Mouth X-Rays: Last Cleaning:
FL
02
2026
/
/
GA /
03
2025
01
2027
01
2027
01
2027
HI
Dental
Hygiene
04
2024
02
2026
02
2026
02
2026
IA
How
do you visit a dentist?
Do you brush your teeth? If yes, how often? Do you floss? If yes, how often?
05 often
2023
03
2025
03
2025
03
2025
ID
Regularly
Yes After every meal
Yes After every meal
06
2022
04
2024
04
2024
04
2024
IL
Occasionally
No
Twice daily
No interested
Twiceindaily
07
2021
Please
list
other dental hygiene aids (Interplak, toothpicks, etc.) that
you
use:
Are
you
regular
hygiene
cleanings?
05
2023
05
2023
05
2023
IN
As
Once daily
Once daily
08 needed
2020
Yes
06
2022
06
2022
06
2022
A few times per week
A few times perKS
week
09
2019
07
2021 No 07
2021
07
2021
Today's
Visit
A few times per month
A few times perKY
month
10
2018
08
2020
08
2020
LA
Do
at this time?08
If yes, 2020
please describe:
Less often
Less often
11 you have
2017any dental problems, pain, or discomfort
09
2019
09
2019
09
2019
MA
Yes
12
2016
10
2018
10
2018
10
2018
MD
No
2015
What is the
main reason for your visit today?
11
2017
11
2017
11
2017
ME
2014
❏ Tooth
❏
Pain ❏ Check-up ❏ Cleaning ❏ Whitening
Cosmetic
Dentistry
12
2016
12
2016
12
2016
MI
2013Dentistry ❏ Restorative Dentistry ❏ Other: 2015
❏ Sedation
2015
2015
MN
2012
2014
2014
2014
What would you like to learn more about?
MO
2011
2013
2013
2013
❏ Whitening ❏ Cosmetic Dentistry ❏ Sedation Dentistry ❏ Implants ❏ Bridges ❏ Veneers
MS
2010
2012
2012
2012
❏ Dentures ❏ Other:
MT
2009
2011
2011
2011
NC
Dental 2008
Concerns
2010
2010
2010
ND
Check all2007
that apply.
2009
2009
2009
NE
Teeth 2006
2008
2008
2008
NH
2005
❏ Broken
❏ Loose/missing filling
❏ Missing
❏
or chipped
teeth
Sensitive
to
sweets
2007
2007
2007
NJ
2004
❏ Crooked
❏ Loose teeth
❏ Mouth
❏
sores
Blisters
on
lips/mouth
2006
2006
2006
NM
2003
❏ Decay
❏ Tooth pain
❏ Sensitive
treatment
2005 to cold
2005❏ Orthodontic
2005
NV
2002
2004 to heat
2004❏ Bad taste
2004
❏ Difficulty chewing
❏ Food trap areas
❏ Sensitive
NYin mouth
2001
2003 when biting2003
2003
❏ Discolored
❏ Grinding or clenching
❏ Sensitive
OH
2000
2002
2002
2002
Gums
OK
1999
2001
2001
2001
❏ Bad breath
❏ Abscessed
❏ Sore
❏ Receding
OR
1998
2000
2000❏ Periodontal
2000
PA treatment
❏ Red (discolored)
❏ Bleeding
❏ Swollen
1997
1999
1999
1999
RI
1996
1998
1998
1998
SC
Page 6/16
1995
1997
1997
1997
SD
1994
1996
1996
1996
TN
What did you like about your last dentist?
What caused you to leave your last dentist?
Pearl Smile Dental
Facial/Jaw Pain
❏ Frequent headaches
❏ Avoid certain foods
❏ Popping/clicking
Other Concerns
❏ Smoking/dipping
❏ Biting cheeks or lip
❏ Popping/clicking
❏ TMJ
❏ Tooth-colored fillings
❏ Wisdom teeth
❏ Nail-biting
❏ Sleep apnea
❏ Limited orthodontics
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
❏ Pain in temples
❏ Jaw locks open/closed
❏ Pain in jaw
❏ Jaw injury
❏ Head injury
❏ Neck injury
❏ Orthodontic treatment
❏ Burning tongue
❏ Tooth replacement
❏ Fractured tooth syndrome
❏ CPAP
❏ Implants - Tooth #:
❏ Jaw locks open/closed
❏ Stain
❏ Chew on one side
❏ Pain around ear
❏ Snoring
❏ Teeth straightening
❏ Retainer
❏ Dry mouth
❏ Wisdom teeth extraction
❏ Cosmetics
❏ Smile makeover
❏ Dental phobias
Does food tend to get caught between your teeth? If yes, where?
Yes
No
Do you hold foreign objects (pencils, pipe, pins, nails, fingernails, etc.) with your teeth? If yes, what?
Yes
No
Have you ever had:
Check all that apply.
❏ Orthodontic treatment
❏ Oral surgery
❏ Periodontal treatment
❏ Your teeth ground
❏ Your bite adjusted
❏ A bite plate or mouth guard
❏ Any canker sores or cold sores on your lips, tongue, gums, or body
❏ A serious injury to the mouth or head? If yes, please describe including cause:
Ratings
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 bad, 5 good), please rate how you feel your overall dental health is.
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 bad, 5 faithful), over the last ten years, rate how faithfully you have had
your teeth cleaned.
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 not sensitive, 5 very sensitive), what is your level of sensitivity to dental
procedures?
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 not sensitive, 5 very sensitive), what is your sensitivity to dental cleaning
appointments?
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 unhappy, 5 very happy), rate how you feel about the look of your smile.
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 poor, 5 great), how do you rate your quality of sleep?
1 2 3 4 5
❍ ❍ ❍ ❍ ❍
On a scale of 1-5 (1 being low, 5 being high), if you snore, how would you rate the severity of
your snoring?
Page 7/16
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Miscellaneous
Has fear ever been an issue for you in a dental office? ❍ Yes ❍ No
Has time ever been a factor in getting your dental work done? ❍ Yes ❍ No
Has the cost of dental treatment been a concern for you? ❍ Yes ❍ No
If yes, how can we help?
Tell us about your good dental experiences/visits:
Tell us about your bad dental experiences/fears:
What do you like most about your teeth/smile?
Is there anything you don't like about your teeth/smile?
Is there anything you'd like to change about your teeth/smile?
What are your long-term dental goals? How would you like your teeth to feel and look?
What are your short-term dental goals?
Do you have any upcoming event or circumstances (such as weddings, major surgeries, etc.) we should/need to know about? If
yes, what and when?
Yes
No
Is
there anything else you feel we should know?
Medical History
How is your general health? ❍ Good
❍ Fair
❍ Poor
Are you currently under medical treatment? If yes, what for?
Yes
No
Do you require antibiotic pre-medication for your dental work? If yes, what for?
Yes
No
Physician's Name:
Phone:
-
Last Visit:
-
/
01
02
03
Do we have permission to contact your doctor regarding your care?
04
05
06
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City:
2027
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❍2024
Yes
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State: ZIP Code:
❍ No
AL
AR
AZ
CA
CO
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Have you ever had:
Check all that apply.
❏ Arthritis
❏ Arteriosclerosis
❏ Birth defects
❏ Cancer
❏ Emotional problems
❏ Head or face injury
❏ Heart murmur/trouble
❏ History of substance
abuse/drug addiction
❏ Kidney problems
❏ Numbness of arms or
hands
❏ Swollen, still 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 or 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
❏ Artificial bones/joints
❏ Shingles
❏ HIV/AIDS
❏ Blood transfusions
❏ Fever blisters
❏ Sinus problems
❏ Severe/frequent
headaches
❏ Cancer/chemotherapy
❏ Radiation treatments
❏ Psychiatric problems
❏ Tuberculosis
❏ Venereal disease
❏ Hemophilia
❏ Abnormal bleeding
❏ Ulcers/colitis
❏ Difficulty breathing
❏ Hospitalized for any
reason
❏ Emphysema
❏ Glaucoma
❏ Thyroid disease
❏ Angina
❏ Artificial hip/joints
❏ Gout
❏ Chest pain
❏ Circulatory problems
❏ Cold sores
❏ 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 adverse reaction or allergies to any medication or substance?
Check all that apply.
❏ Acrylic
❏ Aspirin
❏ Barbiturates (sleeping
pills)
❏ Codeine
❏ Dental anesthetics
❏ Erythromycin
❏ Iodine
❏ Latex rubber
❏ Metals
Page 9/16
❏ Nitrous oxide
❏ Novocaine
❏ Penicillin/antibiotics
❏ Sedatives
❏ Sulfa drugs
❏ Tetracycline
❏ Valium
❏ Xylocaine
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Are you being/have you ever been treated for cancer of any kind? If yes, please explain:
Yes
No
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). ❍ Yes ❍ No
Do you take or have you taken Phen-Fen or Redux? ❍ Yes ❍ No
Do you smoke or chew tobacco? ❍ Yes ❍ No
Do you use alcohol, cocaine, or other drugs? ❍ Yes ❍ No
Do you wear contact lenses? ❍ Yes ❍ No
Are you on a special diet? ❍ Yes ❍ No
Have you lost or gained more than 10 pounds in the past year? ❍ Yes ❍ No
Do you use more than two pillows to sleep? ❍ Yes ❍ No
Have you ever had any excessive bleeding requiring special treatment? ❍ Yes ❍ No
When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness
of breath, or feeling tired? ❍ Yes ❍ No
Have you been treated in a hospital in the last five years? ❍ Yes ❍ No
If female, please mark if you are:
❏ Pregnant - If so, please enter your due date or week #:
❏ Trying to get pregnant ❏ Nursing ❏ On birth control
Please list all current prescriptions:
Please list any other serious medical conditions, impending operations, or other medical/dental information that may possibly
affect your dental treatment:
Do you wish to talk to the dentist privately about any problems/concerns? ❍ Yes ❍ No
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.
Signature (Type your name to sign electronically, or print and sign):
For office use:
Reviewed by:
Title:
Page 10/16
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Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Our Office
What do you already know about our office and what are your expectations?
What would it take for you to trust us to be your dentist?
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?
❏ As a general dentist
❏ As a cosmetic dentist
❏ As a functional (bite, TMJ) dentist
At what point do you want us to initiate treatment for you?
❍ When something isn't ideal
❍ When something worsens
Page 11/16
❍ When my tooth hurts or breaks
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
HIPAA Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can
get access to this information. Please review the following carefully.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires
that all medical records and other individually identifiable health information used or disclosed by us in any
form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the
patient, significant new rights to understand and control how your information is used. HIPAA provides
penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the
privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records for several purposes, including treatment, payment,
defense of legal matters, to family and friends, and health care operations:
Treatment includes providing, coordinating, and/or managing health care related services by one or
more health care providers. An example of this would include teeth cleaning services.
Payment includes such activities as obtaining reimbursement for services, confirming coverage,
billing or collection activities, and utilization review. An example of this would be sending a claim for
your visit to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting
quality assessment and improvement activities, auditing functions, cost-management analysis, and
customer service. An example would be an internal quality assessment review. We may also create
and distribute de-identified health information by removing all references to individually identifiable
information.
To Your Family and Friends: We may disclose your health information to a family member, friend, or
other person to the extent necessary to help with your healthcare or with payment for your
healthcare. Before we disclose your health information to these people, we will provide you with an
opportunity to object to our use or disclosure. If you are not present, or in the event of your
incapacity or an emergency, we will disclose your medical information based on our professional
judgment of whether the disclosure would be in your best interest. We may use our professional
judgment and our experience with common practice to make reasonable inferences of your best
interest in allowing a person to pick up filled prescriptions, medical supplies, X-rays, or other similar
forms of health information. We may use or disclose information about you to notify or assist in
notifying a person involved in your care, of your location and general condition.
In some limited situations, the law allows or requires us to use/disclose your health information without
your permission. Not all of these situations will apply to us; some may never come up at our office at all.
Such uses or disclosures are:
When a state or federal law mandates that certain health information be reported for a specific
purpose
For public health purposes, such as contagious disease reporting, investigation or surveillance, and
notices to and from the federal Food and Drug Administration regarding drugs or medical devices
Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic
violence
Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits
by Medicare or Medicaid; or for investigation of possible violations of health care laws
Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders
Page 12/16
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
of courts or administrative agencies
Disclosures for law enforcement purposes, such as to provide information about someone who is or
is suspected to be a victim of a crime; to provide information about a crime at our office; or to report
a crime that happened somewhere else
Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to
funeral directors to aid in burial; or to organizations that handle organ or tissue donations
Uses or disclosures for health-related research
Uses and disclosures to prevent a serious threat to health or safety
Uses or disclosures for specialized government functions, such as for the protection of the president
or high-ranking government officials; for lawful national intelligence activities; for military purposes;
or for the evaluation and health of members of the foreign service
Disclosures of de-identified information
Disclosures relating to worker's compensation programs
Disclosures of a "limited data set" for research, public health, or healthcare operations
Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
Disclosures to "business associations" who perform healthcare operations for our office and who
commit to respect the privacy of your health information
We may contact you to provide appointment reminders or information about treatment alternatives or
other health-related benefits and services that may be of interest to you. If you wish to be omitted from any
mailings please provide a written notice. Any other uses and disclosures will be made only with your written
authorization. You may revoke such authorization in writing and we are required to honor and abide by that
written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise
by presenting a written request to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosures to family members, other relatives, close personal friends, or
any other person identified by you. We are, however, not required to agree to a requested
restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove
it.
The right to reasonable requests to receive confidential communications of protected health
information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and provide you with
notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of April 5, 2017, and we are required to abide by the terms of the Notice of
Privacy Practices currently in effect.
We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice
provisions effective for all protected health information that we maintain. We will post and you may request
a written copy of a revised Notice of Privacy Practices from this office.
If you think that we have not properly respected the privacy of your health information or that your
privacy protections have been violated, you have the right to file a written complaint to us or the U.S.
Page 13/16
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Department of Health and Human Services, Office for Civil Rights, about violations of the provisions of this
notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
For more information about HIPAA and/or to file a complaint, please call or visit or office or contact:
The U.S. Department of Health & Human Services, Office for Civil Rights
200 Independence Avenue, S.W.
Washington D.C. 20201
(202) 619-0257 Toll Free: 1-877-696-6775
Page 14/16
Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
HIPAA Patient Consent Form
I understand that I have certain rights to privacy regarding my protected health information. These rights
are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPAA or The
Healthcare Privacy Act). I understand that by signing this consent, I authorize Pearl Smile Dental to use
and/or disclose my protected health information to carry out the following:
Treatment which includes direct and/or indirect treatment by other healthcare providers involved in
my treatment.
Obtaining payment from third party payers, i.e. my dental and/or medical insurance
company/companies.
The day to day healthcare operations of your dental practice.
Additionally, I authorize you to share all my protected health information with the following individual(s):
Name:
Relationship:
Phone:
Name:
Relationship:
-
Phone:
Name:
Relationship:
-
Phone:
-
-
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy
Practices, which contains a more complete description of the uses and disclosures of my protected
personal health information, and my rights under HIPAA. I understand that you reserve the right to change
the terms of this notice from time to time and that I may request the most current copy of this notice. I
understand that I have the right to request restrictions on how my protected health information is used and
disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree
to use these requested restrictions. However, if you do agree, you are then bound to comply with this
restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or
disclosure that occurred prior to the date I revoke this consent will not be affected.
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
/
01
02
03
For Office Use Only
04
Patient refused or was unable to sign. Good faith effort was made to obtain acknowledgement of receipt.
05
The following circumstances prohibited the patient from signing the consent form:
06
07
08
Describe your good faith effort to obtain the individual's signature on this form:
09
10
Office Personnel Signature:
Office Personnel Name:
Office Personnel Title:
Date:
11
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If signing on behalf of someone, explain your relationship to the patient:
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Pearl Smile Dental
Pearl Smile Dental
528 West Seminary Dr, Suite A
Fort Worth, TX 76115
817-921-3400
saafwtx1.bptemp29.com
Oral Cancer Screening Form
Our dental practice continually looks for advances to ensure that we are providing the optimum level of
oral healthcare to our patients. We are concerned about oral cancer and look for it in every patient.
One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause of
increasing incidence and mortality rates of oral cancer. As with most cancers, age is the primary risk factor
for oral cancer. Tobacco and alcohol use are other major predisposing risk factors, but more than 25% of
oral cancer victims have no such lifestyle risk factors. Studies also suggest that human papillomavirus
(HPV 16/18) plays a role in more than 20% of oral cancer cases. Oral cancer risk by patient profile is as
follows:
INCREASED RISK: Patients age 18-39, sexually active patients (HPV 16/18)
HIGH RISK: Patients age 40 and older, tobacco users (ages 18-39, any type within 10 years)
HIGHEST RISK: Patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol use);
previous history of oral cancer
Please select one:
❍ YES - I would like to have the oral cancer exam.
❍ NO - I would prefer not to have the oral cancer exam at this time.
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
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