PATIENT DETAILS






















YesNoIs the patient a minor?
GUARDIAN #1 / INSURANCE INFORMATION












INSURANCE (IF APPLICABLE):




SLEEP / AIRWAY ISSUES
YesNoDoes the patient tend to be a mouthbreather?
YesNoDoes the patient snore at night?
YesNoDoes the patient seem rested in the morning?
YesNoIs the patient often sleepy during the day?
YesNoHas the patient seen an Ear, Nose & Throat Specialist?
YesNoIs the patient using a sleep apnea device?
DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

YesNoAcid Reflux
YesNoADHD/ADD
YesNoAIDS/HIV
YesNoAnemia
YesNoArthritis
YesNoAsthma
YesNoAutism
YesNoBone Disorders
YesNoCancer
YesNoCerebral Palsy
YesNoChest Pain
YesNoChronic Neck Pain
YesNoClicking of Jaw
YesNoJaw Pain
YesNoCold Sores/Herpes
YesNoDiabetes
YesNoDown Syndrome
YesNoEndocrine Problems
YesNoEmotional Disorders
YesNoEpilepsy
YesNoHeadaches
YesNoHeart Condition
YesNoHepatitis
YesNoEar Pain
YesNoImmune Problems
YesNoKidney Problems
YesNoLow Blood Pressure
YesNoMuscular Disorders
YesNoNervous Disorders
YesNoOrgan Transplant
YesNoOsteoporosis
YesNoPainful Chewing
YesNoPeriodontal Problems
YesNoProlonged Bleeding
YesNoRheumatic Fever
YesNoScoliosis
YesNoSeizures
YesNoSinus Problems
YesNoTMJ Problems
YesNoTuberculosis

YesNoDo your gums bleed when you brush?
YesNoIs the patient seeing any other dental specialists?
YesNoAny dental restorations needing to be completed?
YesNoHave there ever been any injuries to the face, mouth or chin?
YesNoHave you ever lost or chipped any teeth?
YesNoDo you have any pain or soreness around your face, neck or back?
YesNoIs any part of your mouth sensitive to temperature or pressure?
YesNoIs the patient currently pregnant?
YesNoHave adenoids been removed?
YesNoHave tonsils been removed?
YesNoCurrently taking any medications?
YesNoAre antibiotics necessary prior to treatment?
YesNoAllergies?
YesNoAny diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

YesNoCheek, tongue or lip biting
YesNoClenching Teeth
YesNoFingernail Biting
YesNoGrinding Teeth
YesNoTongue Sucking
YesNoThumb Sucking
YesNoTongue Thrusting
SIGNED CONSENT
Financial Policy

Our goal is to provide you with the best dental care available. A clear understanding of our financial arrangements is essential for a successful doctor/patient relationship.

As a condition of the treatment performed by the providers of Newport Dental Arts; financial arrangements must be made in advance for the full cost of proposed treatment. The practices' vitality depends upon payment for services rendered and it is the responsibility of the patient to satisfy the costs incurred in dental care. Financial arrangements on the part of each individual must be determined prior to treatment completion.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are rendered.

Individuals who carry dental insurance understand that all dental services furnished are charged directly to the patient and that said patient is personally responsible for payment of all dental services provided, regardless of dental insurance reimbursement. As a customer courtesy, this office will help prepare and submit patients' insurance forms as well as assist in making collections from the insurance companies. However, this dental office cannot render services on the assumption that our charges will be paid in part or in full by an insurance company. (Please understand that the amount to be paid by your particular policy is pre-determined and agreed to by your employer and the insurance company. If you have any questions about the amount the plan will pay or the treatment your plan will cover, you should refer these questions to your employer.) Additionally, there may be a deductible, a co-insurance factor, and a yearly maximum to be considered. Most policies cover what they consider a "usual and customary fee". However, the insurance company sets these fees, and they are not always the same as the fees that may be charged in this or any office. All these factors may combine to reduce the benefits you will ultimately receive. We will do our best to see that you receive full benefits within the structure of your particular dental plan. If your insurance company has not paid their portion of the charges within 60 days, the account will revert to your responsibility.

I understand that the fee estimate listed for any proposed dental care can only be extended for a period of three months from the date of diagnosed and/or examination. I further acknowledge that the proposed treatment plan can shift and/or change from the diagnosed treatment plan once treatment is begun due to unforeseen circumstances beyond Dr. Wilhelm's control.

In consideration for the professional services rendered to me by the Doctor; at the providers recommendation or at my own request; I agree to pay, therefore, the reasonable value of services to Doctor, or his assignee, at the time said services 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 allotted for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to Dr. Wilhelm and/or Dr. Wilhelm's financial coordinator, to telephone me at home or at my place of business to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.




Missed Appointment Policy

We strive to provide the utmost in dental care, and we appreciate your trust. Your time with us is exclusive and has been set aside for your treatment. We honor your time and we expect you to honor ours. Your appointment time has been especially reserved for you. Should you be unable to keep your appointment, a minimum notice of 48 business hours is appreciated. Failure to give adequate notice may result in a $50.00 charge. Should you have to change your appointment, please call during business hours.