• Tomas Anderkvist D.D.S
• New Patient Information
• Westwood Dental Smiles

• Welcome to our practice

• Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We look forward to working with you to maintain a healthy happy smile.

• Patient Information

• Today's date

• First Name
• Middle Initial
• Last Name

• I prefer to be called (nickname,etc.)
• Male Female

• Address
• City
• State
• ZIP

• Date of birth
• Social Security Number

• Home phone
• Work phone
• Cell phone

• Primary contact number (please check one)
• Home Office Cell
• Best time to call

• Fax
• Email
• Drivers license #

• Employer
• Occupation

• Spouse's name
• Spouse's Occupation

• Whom may we thank for referring you?

• If the patient is a child

• School
• School phone
• Grade

• Dental History

• Reason for today's visit

• Are you currently in pain?
• Yes No

• If so, please describe:

• Do you have any dental problems now?
• Yes No

• If so, please describe:

• Have you ever had trouble with a previous dental treatment?
• Yes No

• If so, please describe:

• Level of anxiety about seeing the dentist (least)
• 1 2 3 4 5
• (most)

• Date of last dental exam
• Date of last cleaning
• Date of last full mouth X-Rays

• Procedure(s) done at last dental visit

• Previous dentist's name

• City
• State
• phone

• Why are you changing dentists?

• How often do you have dental examinations?
• How often do you brush your teeth?

• How often do you floss?
• What type of bristles do you use?
• Hard Medium Soft

• What other dental aids do you use? (Electric toothbrush, toothpick, etc.)

• 	Yes	No
  Do you require antibiotics before dental treatment?
  Do your gums ever bleed?
  Have you noticed any mouth odors or bad taste?
  Do you bite your lips or cheeks frequently?

• 	Yes	No
  Do you have frequent headaches?
  Do you clench or grind your teeth?
  Are your teeth sensitive to heat/cold?
  Do you still have your wisdom teeth?

• Tomas Anderkvist D.D.S
• New Patient Information
• Westwood Dental Smiles

• Have you ever had:
• Have you ever had:

• 	Yes	No
  Periodontal disease/gum treatment
  Orthodontics treatment
  Oral surgery
  A bite plate or mouth guard

• 	Yes	No
  Discomfort in your jaw joint (TMJ/TMD)
  Your teeth ground or bite adjusted
  Serious injury to the mouth or head
  Bad Experience in a dental office

• If yes to any of the previous questions, please describe

• Is there anything else about your past dental treatment(s) that you would like us to know?

• Patient Information

• Have you been hospitalized or under the care of a medical doctor during the past two years?
• Yes No

• If yes, for what?

• Hospital or Physician's name
• phone

• Have you taken any medications or drugs in the past two years?
• Yes No

• Are you currently taking any medications or drugs? (example: blood thinners, blood pressure meds, antibiotics, aspirin, herbs)
• Yes No

• If yes,please explain

• Have you ever taken Fen-Phen (Diet Drug), Biphosphonates medication for osteoporosis like Fosamax, Boniva...?
• Yes No

• If yes,please explain

• Do you use tobacco in any form?
• Yes No
• Do you use alcohol or any other controlled substance?
• Yes No

• Women Only:

• 	Yes	No
  Are you pregnant or thinking you may be pregnant?
  Are you taking birth control pills?

• 	Yes	No
  Are you nursing?

• Indicate which of the following you have had or have at present:

• 	Yes	No
  AIDS/HIV
  Alcohol/Drug Abuse
  Allergies or Hives
  Anemia
  Arthritis/Rheumatism
  Artificial Heart Valve
  Artificial Bones/Joints
  Asthma
  Blood Disease
  Blood Transfusion
  Bruise Easily
  Cancer/Chemotherapy
  Chest Pain
  Cold Sores/Herpes
  Colitis
  Contact Lenses
  Cortisone Medicine
  Diabetes
  Diet (Special/Restricted)

• • 	Yes	No
    Difficulty Breathing
    Emphysema
    Epilepsy or Seizures
    Fainting or Dizzy Spells
    Frequent Headaches
    Glaucoma
    Hay Fever
    Heart (Surgery, Disease, Attack)
    Heart Pacemaker
    Heart Murmur
    Hemophilia/Abnormal Bleeding
    Hepatitis

  • If Yes Hepatitis
  • A B C

  • 	Yes	No
    High/Low Blood Pressure
    Hospitalized for Any Reason
    Jaundice
    Kidney Trouble
    Liver Disease

• 	Yes	No
  Lupus
  Mitral Valve Prolapse
  Nervousness/Anxiety
  Neurological Disorders
  Psychiatric/Psychological Care
  Radiation Therapy
  Rheumatic/Scarlet Fever
  Shingles/Chicken Pox
  Sickle Cell Disease/Traits
  Sinus Trouble
  Snoring/Sleep Apnea
  Stomach Problems/Ulcers
  Stroke
  Swollen Ankles
  Thyroid Problems
  Tuberculosis (TB)
  Tumors
  Venereal Disease/STD/HPV

• Please list any serious medical condition(s) that you have ever had not listed above:

• Are you aware of having an allergic (or adverse) reaction of the following:

• 	Yes	No
  Aspirin
  Codeine
  Anesthetics (i.e. Novocaine)
  Erythromycin
  Bleach
  Alcohol
  BPA
  Kadmium
  Nickel
  Resins

• 	Yes	No
  Iodine
  Jewelry/Metals
  Latex
  Penicillin or other antibiotics
  Silver/Gold
  Mercury
  Cobalt-Chrom
  Acrylic
  ESTA (ethylenediaminetetraacetic)
  Formaldehyde

• 	Yes	No
  Sedatives
  Sulfa Drugs
  Tetracycline
  Phosphoric Acid
  Methyl Methacrylate
  Zinc Oxide Eugenol
  Mineral Trioxide Aggregate
  Calcium Hydroxide
  Gutta Percha
  Nsaids (Ibuprofen)

• Other

• Patient Signature
• Clear signature

• Tomas Anderkvist D.D.S
• New Patient Information
• Westwood Dental Smiles

• Dental Insurance

• Primary Carrier

• Insurance co. name
• Insurance co. phone

• Address (Street)

• City
• State
• ZIP

• Group no. (Plan or Policy no.)
• Insured's I.D. no.

• Insured's name
• Relationship to patient

• Date of birth
• Insured social security no.

• Insured employer name
• Is insured a patient in our practice?
• Yes No

• Secondary Carrier

• Insurance co. name
• Insurance co. phone

• Address (Street)

• City
• State
• ZIP

• Group no. (Plan or Policy no.)
• Insured's I.D. no.

• Insured's name
• Relationship to patient

• Date of birth
• Insured social security no.

• Insured employer name
• Is insured a patient in our practice?
• Yes No

• Person Financially Responsible for Account

• Name
• Relationship to patient

• Social security no.
• Phone

• Drivers license no.
• Date of birth

• Address (Street)

• City
• State
• ZIP

• Employer
• Work phone

• Preferred payment method
• Cash Credit Card

• Visa/MC/AMEX no.
• Exp. date

• If patient is a minor, name of parent or legal guardian and relationship

• Is insured a patient in our practice?
• Yes No

• Payment is due in full at the time of treatment

• (Unless prior arrangements have been approved)

• I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information including the diagnosis and records of treatment or examination rendered, to my insurance company.

• I the undersigned, hereby authorize the office listed below to charge my credit card for charges not covered on the insurance. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency that may release such information to you. I will notify the dentist of any changes in my health or medication.

• Signature
• Clear signature
• Date

I agree by electronic signature to be contacted by Westwood Dental Smiles through an automated SMS text at my cellular number to review and pay my bill.

• Signature
• Clear signature
• Date

• Person to contact in case of emergency

• Name
• Relationship to patient

• City
• State
• Cell Phone

• Home Phone
• Work Phone

• • OFFICE USE ONLY
  • I VERBALLY REVIEWED THE MEDICAL/DENTAL INFORMATION ABOVE WITH THE PATIENT NAMED HEREIN.
  • Initals:_____________________
  • Date:________________________

• Tomas Anderkvist D.D.S
• Smile Analysis
• Westwood Dental Smiles

• Today's Date
• Patient Number

• 1. Do you love the way your smile looks?
• Yes No

• 2. Do you feel comfortable showing your teeth when you laugh or smile?
• Yes No

• 3. If you could change anything about your smile, it would be (Check all that apply):

• Color of your teeth Size/Shape of your teeth
• Too much or too little of teeth show when you smile Too much or too little of gum shows when you smile
• Gaps between your teeth Alignment of your teeth

• Other:

• 4. Do you have (Check all that apply):

• Sensitive or receding gums Old or discolored fillings
• Worn/broken/chipped teeth Old crowns that have dark edges at the top
• Missing teeth

• Other:

• 5. In your line of work or lifestyle, do you (Check all that apply):

• Visit businesses or clients
• Travel
• Speak publicly

• Other:

• 6. If you had a smile makeover do you think you'd feel (Check all that apply):

• More confident Just OK
• More optimistic No different
• Healthier Other

• 7. Do you or someone in your family have issues with any of the following (Check all that apply):

• Chronic bad breath Grinding teeth Snoring

• Other:

• We'd Like to know more about you so we can better serve you !

• 8. Do you prefer appointments in the (Check all that apply):

• Early morning Late morning
• Early afternoon Late afternoon
• No preference Other:

• 9. Do you have any special dates or upcoming events you'd like us to remember? (weddings, graduations, etc.)

• 10. What type(s) of music do you enjoy? (Optional)

• Easy Listening Jazz
• Classical Country
• Rock R&B
• Hip-Hop/Rap Other:

• 11. What are your favorite hobbies or activities (Optional)

• 12. Is there anything else that you want our office to know about you that will help us to serve you better?

• HIPAA Privacy Rule of Patient Authorization Agreement

• Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

• I,(Patient's Name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

• • a basis for planning my care and treatment;

• • a means of communication among the health professionals who may contribute to my health care;

• • a source of information for applying my diagnosis and surgical information to my bill;

• • a means by which a third-party payer can verify that services billed were actually provided;

• • a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

• I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

• I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility's notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

• Privacy Rule of Patient Consent Agreement

• Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

• I understand that:

• • I have the right to review this facility's Notice of Information practices prior to signing this consent;

• • that this facility reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I've provided, if requested;

• • I have the right to object to the use of my health information for directory purposes;

• • I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this facility is not required by law to agree to the restrictions requested;

• • I may revoke this consent in writing at any time, except to the extent that this facility has already taken action in reliance thereon.

• Signature of Patient or Legal Representative Witness:
• Clear signature

• Printed Name of Patient or Legal Representative Witness:

• Date:

• HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form

• Acknowledgement of Receipt of Information Practices Notice (§164.520(a))

• I,(Patient's Name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I acknowledge that I have been provided with and understand this facility's Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

• • I have the right to review this facility's Notice of Privacy Practices prior to signing this acknowledgment;

• • this facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided, if requested.

• Signature of Individual or Legal Representative Witness:
• Clear signature

• Printed Name of Individual or Legal Representative Witness:

• Date:

• FOR OFFICE USE ONLY

• We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because:

• • Individual refused to sign

• • Communication barrier prohibited obtaining the acknowledgement

• • An emergency situation prevented us from obtaining acknowledgement

• • Other (please specify)

• Privacy Official:

• Date: