New Patient Packet

New Patient? Fill this form.

Name(Required)

First Middle Last

Date of birth(Required)

Preferred name

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email address(Required)

Best way to reach you

Reason for appointment (preventative, pain, concerns)(Required)

Referral Information

Whom can we thank for referring you to our practice?

How did you hear about us?

Insurance

Insurance company

Policyholder's Name

Policyholder's date of birth

Patient relationship to policyholder

Policyholder's ID

Insurance Phone Number

Group/employer name

Group number

Dental History

How long has it been since you last saw a dentist?(Required)

Have you ever been hospitalized or had major operations?(Required)

Yes

If yes explain

Have you ever had a serious head or neck injury?(Required)

Yes

If yes explain

Are you taking any prescription medications?(Required)

Yes

If yes explain

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates ?(Required)

Yes

If yes explain

Women: are you

Pregnant/trying to get pregnant

Nursing

Taking oral contraceptives

Do you have any allergies to any medications or foods?(Required)

Yes

If yes explain

Do you have or have you had Anaphylaxis?(Required)

Yes

Heart pacemaker?(Required)

Yes

Thyroid Disease?(Required)

Yes

Artificial Heartvalve?(Required)

Yes

Hepatitis B or C?(Required)

Yes

Hypoglycemia(Required)

Yes

Kidney problems?(Required)

Yes

Congenital Heart Disorder?(Required)

Yes

Diabetes?(Required)

Yes

Easily Winded?(Required)

Yes

Epilepsy or seizures?(Required)

Yes

Fainting Spells/ dizziness?(Required)

Yes

Hay Fever?(Required)

Yes

High Blood Pressure?(Required)

Yes

Heart Murmur?(Required)

Yes

Stroke?(Required)

Yes

Arthritis/Gout?(Required)

Yes

Hepatitis A?(Required)

Yes

High Cholesterol?(Required)

Yes

Cancer?(Required)

Yes

Chest Pains?(Required)

Yes

Liver Disease?(Required)

Yes

Lung Disease?(Required)

Yes

Osteoporosis?(Required)

Yes

Radiation Treatments?(Required)

Yes

Rheumatism?(Required)

Yes

Shingles?(Required)

Yes

Asthma?(Required)

Yes

Sinus Trouble?(Required)

Yes

Angina?(Required)

Yes

Hemophilia?(Required)

Yes

Ulcers?(Required)

Yes

Breathing Problems?(Required)

Yes

Cortisone Medicine?(Required)

Yes

Leukemia?(Required)

Yes

Irregular Heartbeat?(Required)

Yes

Excessive Bleeding?(Required)

Yes

Emphysema?(Required)

Yes

Drug Addiction?(Required)

Yes

Blood Disease?(Required)

Yes

Heart attack/Failures?(Required)

Yes

Frequent Headaches?(Required)

Yes

Tumors or growth?(Required)

Yes

Heart trouble/disease?(Required)

Yes

Anemia?(Required)

Yes

Chemotherapy?(Required)

Yes

Hives or Rash?(Required)

Yes

Artificial Joint?(Required)

Yes

Mitral Valve Prolapse?(Required)

Yes

Low Blood Pressure?(Required)

Yes

Blood Transfusion?(Required)

Yes

Scarlet Fever?(Required)

Yes

Rheumatic Fever?(Required)

Yes

Pain in Jaw Joints?(Required)

Yes

Bruise easily?(Required)

Yes

Sickle Cell Disease?(Required)

Yes

Have you ever had any serious illness not listed above?(Required)

Yes

If yes explain

Comments?

I certify

To the best of my knowledge, the questions on this form have been accurately answered. I understand that proving incorrect information can be dangerous to my (or my patient's) health. It is my responsibility to inform the dental office of any changes in the medical status.

Date(Required)

Signature(Required)

Notice of privacy practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 10/01/2007, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH
INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
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Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost- based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $25.00 for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost- based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND CONCERNS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Telephone: (978) 468-7746
Fax: (978) 468-2146
E-Mail: office@greenwillowdental.com
Business Address: 205 Willow Street, Suite B, South Hamilton, MA 01982

I read this office's Notice of Privacy Practices above.

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

Office Financial Policy (Updated January 2024)(Required)

We try to make your dental care as cost-efficient as possible. One measure we have taken to keep costs down is to minimize our billing and accounting; therefore, we ask for payment at the time of service. Financial arrangements must be established before our office can proceed with any recommended treatment.

All patients who are seen in our office for a comprehensive exam are provided with a treatment plan. This is an estimate of the anticipated cost of your dental treatment. Your treatment plan will include an estimated insurance payment based on your dental coverage. If your carrier’s payment differs from our estimate, you are responsible for the balance. In the case of overpayment, you are entitled to a prompt refund. Any claims over 90 days become your responsibility.
In cases of divorce or separation, the parent bringing the child is responsible for payment.

Cancellation Policy
If it becomes necessary to reschedule your appointment, we request the courtesy of 48 hours’ notice. If you cancel, do not show, or miss your appointment without the required notice, we will assess a broken appointment fee of $97.00 for cleanings and $97.00 for appointments with the dentist. These fees are strictly enforced and will not be covered by your insurance.
If you have any questions regarding your account balance, or if you are experiencing circumstances beyond your control, please contact our office. We will be happy to assist you with your questions or to set up special payment arrangements.
Our practice firmly believes that a good doctor/patient relationship is based upon a clear understanding of office policies and an open line of communication. We have instructed our staff to make every effort to clarify any misunderstandings you may have concerning your account balance or our financial policies. We hope to avoid any possible disagreements over payment for professional services.
Our patients and our relationships with our patients are very important to us. If you have any questions or need assistance, please contact us immediately.

I read and accept the Office Financial Policy

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Signature(Required)

(parent, legal guardian, or POA of the patient, if patient is unable to sign themselves)

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Referral Information

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Dental History

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