New Patient Form
Dr. Daniel C. Sluyk, DDS
Patient Name
Mr/Dr/Mrs/Ms
First Name
Middle Name
Last Name
Preferred Name
Gender
Male
Female
This field is required.
Family Status
Married
Single
Child
Other
This field is required.
Birth Date
SSN
Date of Last Dental Visit
Last X-Rays
Email Address
Primary Email
Best time to call
Phone
Address
Street Address
Street Address Line 2
City
State
Postal
Name of Previous Dentist
Whom may we thank for referring you to our practice?
In an emergency, who should be notified?
Please enter Name and Phone Number
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Check all of the following that you may have had in the past or that currently apply to you:
AIDS/HIV Positive
Alzheimer's Disease
Anemia
Angina
Arthritis
Artificial Joint
Asthma
Atrial Fibrillation
Blood Disease
Blood Transfusion
Bruise Easily
Cancer*
Chemotherapy
Chest Pains
Cognitive Disorders
Cold Sores/Fever Blisters
Congenital Heart Disease
Dementia
Diabetes*
Elevated Cholesterol
Emphysema/COPD
Epilepsy or Seizures
Excessive Bleeding
Fainting/Dizzy Spells
Glaucoma
Gout
Heart Attack*
Heart Disease
Heart Murmur
Hemophilia
Hepatitis A, B, or C
Herpes
High Blood Pressure
Irregular Heartbeat
Kidney Problem/Disease
Liver Problem/Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pacemaker/Defibrillator
Parathyroid Disease
Psychiatric Care
Radiation Treatment
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble/Infections
Sleep Apnea-CPAP
Sores/Growths in Mouth
Stroke
Thyroid Disease
Tuberculosis
Tumors or Growths
Ulcer
Others*
This field is required.
*If you've selected Cancer, Diabetes (A1C), Heart Attack, or Other, please provide more details:
Are you allergic to or have you reacted adversely to any of the following medications? Please check all that apply.
Aspirin
Erythromycin
Tetracycline
Codeine
Latex
Penicillin/Amoxicillin
Sulfa
Local Anesthetic
This field is required.
Other:
Have you ever taken any of the following medications? Please check all that apply, and provide start/end dates.
Actonel
Boniva
Risedronate
Alentronate
Fosamax
Zometa
Aredia
Reclast
Prolia/Denosumab
Herbal Supplements
This field is required.
Are you currently taking any medications? If yes, please list:
Do you need antibiotics prior to receiving dental care? If so, which type/dosage?
Do you take Coumadin or Plavix or any other blood thinner? If yes, do you know your typical INR?
Please describe your present health
Excellent
Good
Fair
Poor
Don't Know
This field is required.
When was your last visit with your primary care physician?
Are you currently under a physician’s care? If yes, please list reason:
Has there been any change in your general health in the past year? If yes, please explain:
Please list any other serious illness, hospitalization, or condition in the last 5 years if not listed above:
Are you a past or present smoker/vaper?
Yes
No
This field is required.
If yes, how many cigarettes/cigars/mg per day?
Do you have any history of substance abuse, or do you currently use recreational drugs?
Yes
No
This field is required.
Signature
Clear
Signature is mandatory.
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Primary Dental Insurance
Insurance Plan Name
Phone Number for Provider Services
Name of Insured
First Name
Last Name
Insured's Birth Date
Plan ID
Insured's SSN
Group #
Insured's Address
Street Address
Street Address Line 2
City
State
Country
Postal
Patient's Relationship to insured
Self
Spouse
Child
Others
This field is required.
Secondary Dental Insurance
Insurance Plan Name
Phone Number for Provider Services
Name of Insured
First Name
Last Name
Insured's Birth Date
Plan ID
Insured's SSN
Group
Insured's Address
Street Address
Street Address Line 2
City
State
Country
Postal
Patient's Relationship to insured
Self
Spouse
Child
Others
This field is required.
Insurance Authorization - please complete for payment of insurance benefit
I authorize my insurance(s) to pay my benefits directly to the dentist for all services rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges, whether or not paid by insurance.
This field is required.
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Dental Information
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
This field is required.
How often do you routinely see your dentist?
3 Months
4 Months
6 Months
12 Months
This field is required.
What is your immediate concern?
Are you fearful of dental treatment? If yes, how fearful, on a scale or 1 (least) to 10 (most)
Personal history, check all that apply:
Had an unfavorable dental experience
Had complications from past dental treatment
Had trouble getting numb
Had any reactions to local anesthetic
Had/have braces, orthodontic treatment
Had your bite adjusted
Had any teeth removed
This field is required.
Smile Characteristics, check all that apply:
Is there anything about the appearance of your teeth that you would like to change?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you ever whitened (bleached) your teeth?
Have you been disappointed with the appearance of previous dental work?
This field is required.
Bite and Jaw Joint, check all that apply:
You have problems with your jaw joint
You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
You have any problems chewing
You clench your teeth in the daytime or make them sore
Your teeth changed in the last 5 years, have become shorter, thinner, or worn
You have problems with sleep, or wake up with an awareness of your teeth
Your teeth are crowding or developing spaces
You wear or have worn a bite appliance
This field is required.
Tooth Structure, check all that apply:
Cavities within the past 3 years
The amount of saliva in your mouth seems too little, or you have difficulty swallowing food
You notice or have holes (i.e., pitting, craters) on the biting surface of your teeth
Your teeth are sensitive to hot, cold, biting, sweets, or you avoid brushing any part of your mouth
Your teeth have grooves, notches, chips, a cracked filling, or pain
Food gets caught between your teeth
This field is required.
Gum and Bone, check all that apply:
Gums bleed when brushing or flossing
Treated for gum disease or were diagnosed with bone loss
Noticed an unpleasant odor or taste in your mouth
History of periodontal disease in your family
Experienced gum recession
Had any teeth become loose on their own (without injury) or have difficulty eating an apple
Experienced a burning sensation in your mouth
This field is required.
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Financial Policy
DENTAL INSURANCE
USUAL AND CUSTOMARY RATES
Signature
Clear
Signature is mandatory.
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Cancellation Policy
MISSED APPOINTMENTS
LATE ARRIVAL
DR. SLUYK & LIFEGUARD ANESTHESIA SEDATION APPOINTMENTS
Signature
Clear
Signature is mandatory.
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HIPAA Acknowledgment
Signature
Clear
Signature is mandatory.
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Informed Consent for Local Anesthesia
Signature
Clear
Signature is mandatory.
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Social Media & Photography/Video Consent
Signature
Clear
Signature is mandatory.
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Consent for Internet Communications
Signature
Clear
Signature is mandatory.
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Add a Card on File
Card Number
Type a sub label
Name on Card
CVC Code
Expiration
Type a sub label
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New Patient Form | Dr. Daniel C. Sluyk, DDS