New Patient Forms


We are so very excited that you are interested in becoming a patient of ours. We know that you will fall in love with the care you receive from our highly trained staff. You will never again have a dental horror story to share at the water cooler or at the company Christmas party!

Prior to your first appointment we will need you to fill out our new patient forms. These form will allow us to best server you and your family. You will find a both a PDF and a Microsoft Word© version of the forms in the links below. You are welcome to fill them out from our site prior to your appointment or you can also get these forms on the day of your appointment. As your new Boise dentist, please let us know if there’s anything we can do for you!

All fields marked with an asterisk (*) are required.

 

Patient Information

First Name *

Last Name *
Preferred Name:

Email Address *
Patient Is:  Policy Holder Responsible Party

Address:

City,State, Zip:

Emergency Contact Name:

Emergency Contact Phone:
Home Phone:

Work Phone:

Mobile Phone:

Sex:  Male Female
Marital Status:  Married Single Divorced Separated
Birth Date:

Age:
Driver's License Number:

Social Security Number
Would you like to receive correspondences via email?  Yes No

 

Responsible Party (if other than the patient)

First Name:

Last Name

Address:

City, State, Zip:

Birth Date:
Home Phone:

Work Phone:

Mobile Phone:

Driver's License Number:

Social Security Number
 Responsible Party is also a Policy Holder for Patient
 Primary Insurance Policy Holder
 Secondary Insurance Policy Holder

 

Primary Insurance Information

Insurance Company:

Address:

City, State, Zip:

Plan Name:
Employer:

Employer ID#:

Employer Address:

City, State, Zip:
Relationship to Patient:  Self Spouse Child Other

 

Secondary Insurance Information

Insurance Company:

Address:

City, State, Zip:

Plan Name:
Employer:

Employer ID#:

Employer Address:

City, State, Zip:
Relationship to Patient:  Self Spouse Child Other

 

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
 Yes No - If yes, please explain:
Have you ever been hospitalized or had a major operation?
 Yes No - If yes, please explain:
Have you ever had a serious head or neck injury?
 Yes No - If yes, please explain:
Are you taking any medications, pills, or drugs?
 Yes No - If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
 Yes No - If yes, please explain:
Are you on a special diet?
 Yes No - If yes, please explain:
Do you use tobacco?
 Yes No
Do you use controlled substances?
 Yes No

Women, are you...

Pregnant or trying to get pregnant?
 Yes No - If yes, please explain:
Taking oral contraceptives?
 Yes No - If yes, please explain:
Nursing?
 Yes No - If yes, please explain:

Are you allergic to any of the following?


If yes, please explain:

Health History

Do you have, or have you had, any of the following?

 Yes No - AIDS/HIV Positive
 Yes No - Alzheimer's Disease
 Yes No - Anaphylaxis
 Yes No - Anemia
 Yes No - Angina
 Yes No - Arthritis / Gout
 Yes No - Artificial Heart Valve
 Yes No - Artificial Joint
 Yes No - Asthma
 Yes No - Blood Disease
 Yes No - Blood Transfusion
 Yes No - Breathing Problem
 Yes No - Bruise Easily
 Yes No - Cancer
 Yes No - Chemotherapy
 Yes No - Chest Pains
 Yes No - Cold Sores / Fever Blisters
 Yes No - Congenital Heart Disorder
 Yes No - Convulsions
 Yes No - Cortisone Medicine
 Yes No - Diabetes
 Yes No - Drug Addiction
 Yes No - Easily Winded
 Yes No - Emphysema
 Yes No - Epilepsy or Seizures
 Yes No - Excessive Bleeding
 Yes No - Excessive Thirst
 Yes No - Fainting Spells / Dizziness
 Yes No - Frequent Cough
 Yes No - Frequent Diarrhea
 Yes No - Frequent Headaches
 Yes No - Genital Herpes
 Yes No - Glaucoma
 Yes No - Hay Fever
 Yes No - Heart Attack/Failure
 Yes No - Heart Murmur
 Yes No - Heart Pace Maker
 Yes No - Heart Trouble / Disease
 Yes No - Hemophilia
 Yes No - Hepatitis A
 Yes No - Hepatitis B or C
 Yes No - Herpes
 Yes No - High Blood Pressure
 Yes No - Hives or Rash
 Yes No - Hypoglycemia
 Yes No - Irregular Heartbeat
 Yes No - Kidney Problems
 Yes No - Leukemia
 Yes No - Liver Disease
 Yes No - Low Blood Pressure
 Yes No - Lung Disease
 Yes No - Mitral Valve Prolapse
 Yes No - Pain in Jaw Joints
 Yes No - Parathyroid Disease
 Yes No - Psychiatric Care
 Yes No - Radiation Treatments
 Yes No - Recent Weight Loss
 Yes No - Renal Dialysis
 Yes No - Rheumatic Fever
 Yes No - Rheumatism
 Yes No - Scarlet Fever
 Yes No - Shingles
 Yes No - Sickle Cell Disease
 Yes No - Sinus Trouble
 Yes No - Sleep Trouble
 Yes No - Spina Bifida
 Yes No - Stomach / Intestinal Disease
 Yes No - Stroke
 Yes No - Swelling of Limbs
 Yes No - Thyroid Disease
 Yes No - Tonsillitis
 Yes No - Tuberculosis
 Yes No - Tumors or Growths
 Yes No - Ulcers
 Yes No - Venereal Disease
 Yes No - Yellow Jaundice

 

Financial Policy

This is an agreement between Modern Dental & Orthodontics and the patient. By executing this agreement, you are agreeing to pay for all services received.

Payments: Payment for services is expected at the time of service unless we approve other arrangements in writing prior to your appointment. Accounts are considered past due if not paid within 20 days of receipt of your statement.
If you do need monthly payments we do offer care credit.

Payment options if you have insurance:
A. You may pay your portion at time of service by Cash, Check, Visa, Master Card, Discover, American Express or Care Credit.
B. On extensive treatment (crowns, bridges, etc) you may pay 50% of your portion at the preparation date and the balance at the delivery date.

Payment options if you have no insurance:
A. You may pay by Cash, Check, Visa, Master Card, Discover, American Express or Care Credit.
B. On extensive treatment (crowns, bridges, etc) you may pay 50% of your portion at the preparation date and the balance at the delivery date.

Monthly statements: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, the finance charge, if any, and any payments or credits applied to your account during the month.

Late Fee $25. Finance Charge: A Finance charge may be imposed on each item of your account which has not been paid within thirty (30) days of the time the item was added to the account. The finance charge will be computed at the rate of (1.5%) per month or an annual percentage rate of (18%). The minimum finance fee is $2.50.

Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract. We will bill your insurance company as a courtesy to you. Although we will estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree and understand that You are responsible for benefits, payments, or any claim inquiries including yearly maximums.

Returned Checks: There is a fee (currently $25) for any checks returned by the bank.

Missed appointment fee: WE require at least a 24-hour notice in order to change any appointments. There may be a $50.00 fee for all appointments that are missed or cancelled less than 24 hours in advance.

Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the costs that are incurred, If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees which we incur plus all court costs. In case of suit, the venue shall be in Ada County.

Waiver of Confidentiality: If this account is referred to an attorney or collection agency or if we have to litigate in court, the fact that you received treatment in office will become a matter of public record.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After the divorce or separation, the parent authorizing treatment for the child will be the parent responsible for those charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

For patients with Insurance: I hereby assign all dental benefits, to include major dental benefits to which I am entitled, including private insurance and any other health plans, to Chad Roskelley DDS and Ted Wagner DMD

I acknowledge the Notice of Privacy Practices of this office posted at the front desk. Upon my request a copy of this information will be supplied to me.

Comments

By typing my name below, I agree to the following:
To the best of my knowledge, the questions on this form have been accurately answered. 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 also agree to the Financial Policy above.
Electronic Signature*