Patient Information

___________________________________________	__________________________________________	 	__________________________
Patient Name (last, first, MI)		Preferred Name	Date

Gender: ______      Married: _____      Single: ______     Age: _______               Email Address _________________________________________

Social Security # _______________________________________________________	Date of birth ______________________________________

Phone (home) ______________________________ (work) ____________________________ ext. ______  (cell) ________________________________

Address ____________________________________________________________________________________________________________________	Street	Apartment #		City, State, Zip Code
Spouse or Responsible Party Information      

_________________________________________________________________              Male   Female              Married  Single  Child  Other
Name (last, first, MI)

Social Security # ______________________________________________________________  	Date of birth  _______________________________

Phone (home) ____________________________ (work) _____________________ ext. ______  (cell) ________________________________

Address  ___________________________________________________________________________________________________________________
                 Street                                                             Apartment #                                                                         City, State, Zip Code
Insurance Information 

Primary Insurance Company Name: 						

Name of insured _____________________________________________   Relationship to patient  self    spouse    child    other ______________

Insured’s birth date ______________________________________________________  ID # _____________________ Group # ____________________

Secondary Insurance Company Name: 					

Name of insured _____________________________________________  Relationship to patient  self    spouse    child    other _______________

Insured’s birth date __________________________________________________  ID # _____________________ Group # _______________________

Consent for Services
As a condition of my treatment by this office, payment is expected in full at time of service. If financial arrangements are necessary they must be made in advance. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.  I agree that interest will accrue on all past-due amounts over 30 days at the rate of 18% per annum (1.5% per month) until paid in full. 

I understand that it is my responsibility to provide my correct/updated insurance information and that this office will bill my insurance as a courtesy to me. However, regardless of insurance coverage, I agree that it is and shall remain my responsibility to pay all amounts owing as set forth herein. If I carry dental insurance I understand that all dental services furnished are charged directly to me and that I am personally responsible for payment of all dental services. This office will help prepare insurance claims or assist in making collections from insurance companies and will credit any such collections to my account. However, this dental office cannot render services on the assumption that my charges will be paid by an insurance company. 

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that in addition to any other amount(s) allowed for by law, (such as interest, court costs, reasonable attorney’s fees, etc.)  I will also be responsible for a collection fee of up to 40% of the principal amount(s) owing as allowed by Utah Code Annotated, see, 12-1-11. The terms of this paragraph shall apply to all amount(s) incurred by me or by any individual for whom I have legal responsibility whether such amount(s) are incurred today or after today. 

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters/leave messages (either voicemail or with a family member) related to this form. This agreement supersedes all prior agreements signed, including any and all mediation or mediation/arbitration agreements. I acknowledge that any prior mediation or mediation/arbitration agreements signed previously related to financial arrangements or quality of care are null and void.  I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or in paper form to my insurance carrier or any related entities that require such information to be submitted.

I acknowledge that I have been given the opportunity to receive a copy of Dr. Clark B. Hicken’s Notice of Privacy Practices. I have also had a chance to review the Notice of Privacy Practices in the office. I understand that Personal Health Information may be used and disclosed for treatment, payment, or healthcare operations. I understand that I have the right to review Dr. Clark B. Hicken’s privacy notice at any time. I have a right to request restrictions and/or revoke consent in writing if agreed to by Dr. Clark B. Hicken. I agree to disclose to the dentist names of any individuals with whom I authorize the dentist to discuss my dental care.

* It is the responsibility of the patient not the dental office to know what is covered and what is excluded from her or his own dental plan. We will do our best to inform you of what we know of your dental plan but ultimately you are responsible for any and all charges not covered.

Signature  	     	                                 Date:	         Relationship to patient 				 

Health Information

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private. 

1.	Are you being treated for any medical condition at the present time or have you been treated within the past year? If so, why?    Yes    No   

__________________________________________________________________________________________________________________
2.	When was your last dental checkup?
__________________________________________________________________________________________________________________
3.	Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.   Yes    No   

		__________________________________________________________________________________________________________________
4.	Do you have any allergies? If you answered yes, please list using the categories below:    Yes   No  
a.	Medications (please list)
b.	latex/rubber products
c.	other e.g. hayfever, foods
d.	other (please explain)
		__________________________________________________________________________________________________________________
5.	Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. 	 Yes    No   

	__________________________________________________________________________________________________________________
6.	Have you ever been advised by your doctor to take antibiotics before dental treatment?  Yes   No  
	__________________________________________________________________________________________________________________
7.	Do you have a prosthetic or artificial joint?    Yes    No   
__________________________________________________________________________________________________________________
8.	Have you ever been hospitalized for any illnesses or operations? If yes, please explain.  Yes    No   

__________________________________________________________________________________________________________________
9.	Do you have or have you ever had any of the following? Please check.

	 AIDS	 Drug/alcohol dependency	 Kidney disease	 Radiotherapy/steroid therapy
	 Anemia	 Glaucoma	 Leukemia	 Rheumatic fever
	 Arthritis	 Heart attack	 Liver disease	 Seizures (epilepsy)
	 Asthma	 Heart disease	 Lung disease	 Sinus problems
	 Bleeding disorder	 Heart murmur 	 Mental disorders	 Stomach ulcers
	 Cancer	 Hepatitis (Type)           	 Mitral valve prolapse	 Stroke
	 Chemotherapy treatment	 High blood pressure	 Nervousness/Anxiety	 Tuberculosis
	 Depression	 HIV	 Pacemaker	 Thyroid disease
	 Diabetes	 Jaundice	 Prosthetic heart valve	 Venereal disease

	 Other (please explain)	__________________________________________________________________________________________________________________
10.	Who is your primary care physician?  
__________________________________________________________________________________________________________________
11.	Are there any conditions or diseases not listed above that you have or have had? If so, what?  Yes    No   
12.	
__________________________________________________________________________________________________________________
13.	Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)  Yes    No   

__________________________________________________________________________________________________________________
14.	Do you smoke or chew tobacco products?    Yes    No   
__________________________________________________________________________________________________________________
15.	For women only: Are you breast-feeding or pregnant? If pregnant, what is the expected delivery date?  Yes    No   
	__________________________________________________________________________________________________________________
16.	Are you nervous during dental treatment?    Yes    No   
	__________________________________________________________________________________________________________________
17.	Rate your smile from 1 (poor) to 10 (excellent).   If you could change anything about your smile, what would it be?
 
__________________________________________________________________________________________________________________
18.	What are your hobbies or interests?  What do you do for work?

	__________________________________________________________________________________________________________________

Referral Information

Whom may we thank for referring you to our practice?      another patient, friend/relative  (Name) 						
	
 Dental office     Yellow pages     Newspaper     School     Work     Other  _____________________________________________________

To the best of my knowledge, all of the preceding answers and information provided are true and correct.  If I ever have any change in my health, I will inform the doctors at the next appointment without fail. I certify that I have answered all questions in this form accurately and to the best of my knowledge. I have read the above conditions of treatment and payment and agree to their content.  

______________________________________________________________________________	________________________________
Signature of patient, parent or guardian	Date