Patient Forms

Complete your paperwork online before your visit

Your information goes straight into our system — no paper, no portal logins. New patients: complete the full form below. Already a patient? Use the Returning Patient tab.

New Patient Form

Fill this out once before your first visit. Takes about 5 minutes.

Your Office

Which location? *

About You

The patient is a/an: *

Adult Child Adult under Guardianship

First Name *

Middle Name

Last Name *

Preferred Name

Date of Birth *

Preferred Pronouns

He/Him She/Her They/Them Other Prefer not to say

Title

Gender

Marital Status

Contact Info

Street Address *

Apt / Suite / Unit #

City *

State *

ZIP Code *

Cell Phone *

Home Phone

Work Phone

Email *

Occupation

Employer *

Preferred method of contact

Phone Call Text Email

How did you hear about us? *

If other, please specify

Insurance

Do you have dental insurance? *

Yes No

Are you the subscriber?

Yes No

Subscriber Name

Subscriber Date of Birth

Primary Insurance

Insurance Carrier

Member / Subscriber ID

Group / Plan #

Secondary Insurance (if any)

Insurance Carrier

Member / Subscriber ID

Group / Plan #

Parent / Guardian

Full Name

Relationship to Patient

Phone

Emergency Contact

Someone we can reach if we need to inform you about your condition. Please provide contact different from yours.

Full Name

Relationship to Patient

Phone

Dental History

Is there a dental problem you want treated immediately?

Yes No

Do you have dental anxiety? If yes, please explain:

Reason for today's visit

Date of last dental visit

Last dental cleaning

Last dental x-ray

Are you having regular dental visits?

Yes No

Have you ever had any of the following?

Periodontal Treatment Bite adjusted or teeth ground Orthodontic Treatment Oral Surgery Bite plate or appliance

Do you feel you have bad breath?

Yes No

How often do you brush your teeth?

Do you use dental floss or other interproximal tools?

Yes No

Do your gums bleed when brushing or eating, or do you suffer from gum pain or swelling?

Are any of your teeth sensitive to heat, cold, sweets, or pressure?

Have you ever experienced any of the following jaw problems?

Popping / clicking in jaw joints Pain when teeth are clenched Pain in jaw joints, around ear, or side of face Pain or difficulty when chewing Difficulty opening or closing

Do you have any of the following habits?

Clenching or grinding teeth Placing foreign objects in mouth Biting cheeks or lips Mouth breathing while awake or asleep

Medical Physician Name

Medical Physician Phone

Medical History

Are you being treated for any medical condition at present or within the past years? Please explain:

Have there been any changes in your general health in the past year?

Medications

Medication Name

Comments / Dosage

List any other prescription or non-prescription drugs you are taking or have recently taken:

Have you ever had any adverse or unusual reaction to any medications or injections (e.g. penicillin, antibiotics, aspirin, codeine, local anesthetic)? If yes, please explain:

Have you ever been advised against taking any specific type of medication?

Allergies — check all that apply:

Aspirin Hay Fever Latex Metals Sulfa Food allergies Rubber

Any other allergies not listed above:

Have you ever fainted during dental or medical treatment?

Yes No

Do you bleed excessively from a cut/injury, bruise easily, or have any blood disorders? If yes, please explain:

Do you have any artificial joints (e.g. hip, knee)?

Yes No

Please check all conditions you presently have, or have ever had:

Asthma Back Problems Bronchitis Cancer Chemical Dependency Chemotherapy Diabetes Difficulty Breathing Emphysema Epilepsy Facial / Jaw Surgery Fainting Glandular Disorders Headaches Heart Attack Heart Murmur Hemophilia Hepatitis High Blood Pressure HIV Jaundice Jaw Pain Joint Replacement Kidney Disease Kidney Problems Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Organ Transplant / Implant Pace Maker Psychiatric Problems Radiation Therapy Rheumatic Fever Scarlet Fever Seizures Shingles Sinus Problems STDs Stomach / Intestinal Problems Stroke Thyroid Problems Tuberculosis Ulcers

Any other problems or conditions not listed above:

Is there anything else about your health we should be made aware of, or do you wish to speak to the doctor privately about any condition?

Women only — if applicable:

Are you pregnant?

Yes No

If pregnant, expected delivery date:

Are you breastfeeding?

Yes No

Sleep screening:

Do you snore?

Yes No

Has anyone told you that you stop breathing or gasp during sleep?

Yes No

Do you feel tired during the day even after a full night of sleep?

Yes No

Agreements & Consents

COVID-19 Acknowledgment

Daily Dental & BracesBar has established safety and sterilization protocols designed to prevent the spread of COVID-19 and is managing these measures in conjunction with the guidelines of the American Dental Association and Ohio Board of Dentistry. By agreeing to receive treatment and/or dental care, you may be exposed to virus-related risks that cannot be managed, controlled or totally eliminated. By checking below, you hereby agree and acknowledge that the Practice, and its professional staff and employees, cannot control all risks associated with the COVID-19 virus and agree that the Practice should not be legally responsible for possible exposure to the COVID-19 virus.

I have read and agree to the COVID-19 acknowledgment above.

Financial Arrangement

I understand the proposed dental treatment plan, including the potential benefits, risks, and alternative options, and I consent to the recommended treatment and authorize the Dr. to perform the necessary procedures. I authorize my insurance company to make payment directly to this office. I understand that I am responsible for all charges whether or not they are covered by insurance. We do require a $50 reservation fee. The $50 is applied towards your estimated out-of-pocket. If you need to cancel the appointment, please notify the office more than 24 hours prior to the appointment, or else the $50 will not be refunded. If the patient fails to show up for the scheduled appointment, the $50 will not be refunded.

I have read and agree to the Financial Arrangement above.

HIPAA — Notice of Privacy Practices

I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to the use and disclosure of my protected health information (PHI) in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission. I give permission for this office to send my records and patient information to other doctors and referring offices. I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information, and that this information can be used to: conduct, plan and direct my treatment; obtain payment from third party payers; and conduct normal healthcare operations.

I have read and agree to the HIPAA Notice of Privacy Practices above.

HIPAA Authorization for Release of Health Information — Optional (45 CFR §164.508)

Complete this section only if you want to authorize someone else to access your health information. Signing is voluntary and will not affect your care.

Recipient name — who may receive your information

Recipient relationship to you

Health information to be released

Purpose of disclosure

Authorization expires on

I authorize daily DENTAL & bracesbar to disclose my health information as described above to the recipient named. I understand I may revoke this authorization in writing at any time by notifying the office. Revoking this authorization will not affect any actions taken before revocation. I understand that once my information is disclosed, the recipient may re-disclose it and it may no longer be protected by HIPAA. I am entitled to a copy of this signed authorization.

I authorize the release of my health information as described above.

Permission to Use Photographs and X-Rays

I consent to the taking of photographs and X-rays before, during and after treatment as they are a necessary part of the diagnostic procedure and record keeping. I further give permission for the use of these photographs, X-rays and records to be used for the purpose of research, education and/or publication in professional journals.

I consent to the use of photographs and X-rays as described above.

Signature (type your full name) *

By typing your name above you are providing your electronic signature and confirming that all information provided is accurate and complete.

Sent securely to your selected office. We will never share your information.

Welcome Back!

Thank you for trusting daily DENTAL & bracesbar! Please take a moment to update us on any changes since your last visit.

Your Info

First Name *

Last Name *

Date of Birth *

Which office? *

What's Changed Since Your Last Visit?

New allergies:

New medications:

New surgeries:

Do you have a new mailing address?

Yes No

New street address

City

State

ZIP

Current email address

Current cell phone

Current employer

Current dental insurance

Appointment Reminders

Preferred reminder method

Phone call to home Phone call to cell Email Text message

Sleep Screening

Do you snore?

Yes No

Has anyone told you that you stop breathing or gasp during sleep?

Yes No

Do you feel tired during the day even after a full night of sleep?

Yes No

Sent securely to your selected office.

Mon	9 AM – 7 PM
Tue	11 AM – 7 PM
Wed	8 AM – 2 PM
Thu	8 AM – 3 PM
Fri	8 AM – 2 PM
Sat	8 AM – 2 PM
Sun	By Appointment

Mon	8 AM – 7 PM
Tue	9 AM – 6 PM
Wed	10 AM – 7 PM
Thu	9 AM – 6 PM
Fri	8 AM – 2 PM
Sat	8 AM – 2 PM
Sun	8 AM – 1 PM

Mon	8 AM – 3 PM
Tue	10 AM – 7 PM
Wed	10 AM – 7 PM
Thu	9 AM – 3 PM
Fri	9 AM – 2 PM
Sat	8 AM – 2 PM
Sun	8 AM – 1 PM