New Patient Form Healthpark Dentistry

New Patient Form (Dentrix) Date ______Staff ______Name ______Preferred Name ______Do you have some specific problem we should know about? ______

ADULT -- You have a choice for your first visit. We can either clean your teeth or you can have a thorough exam. Most who visit us for the first time prefer a thorough exam rather than a cleaning appointment. The Doctor will spend about ½ hour with you - getting to know you and what you expect from your dentist. Then the doctor will provide you a very thorough exam and review our findings with you, so you can decide what your treatment priorities are. Can I schedule this appointment for you today? Wants NP exam ______doesn’t want NP exam ______Why? ______Have you had a complete set of x-rays in the last 3-5 years? ______(If yes, please bring or have sent to us.)

CHILDREN -- Do you have children that need a dental check-up? _____ For children that visit us for the first time we suggest preventive care training. One of our Preventive Care Specialists will spent about ½ hour with you and your child going over brushing, flossing, and nutrition followed by an exam with the Doctor. Can I schedule this appointment for you today?

Wants NP exam _____Doesn’t want NP exam ______why? ______Do you have a preference for which Doctor you would like to see? (www.healthparkdentistry.com) Dr. ______Dr. ______Dr. ______Are there other family members we can get started? ______Who can we thank for referring you to our office? (Enter into Dentrix: referral source) Do you know where we are located? So what made you decide to schedule an appt with us today? ______Anything we should know to make you as comfortable as possible?______Attitude: (circle) frightened shy hostile very pleasant money concerns

NP checklist  If Superior, Aetna (&Aetna Vital Savings), Anthem, Delta, DentaSelect, or Dental Care Plus – Name in ALL CAPS  Referral source noted  Changed to ______(Provider color ) & note NEW  Mailed NP packet / Emailed NP letter- Date______ Contact previous dentist for records transfer______ Update all patient info into family file  Fee schedule selected (1- Regular, 4– Superior, 6-Aetna, 7-DentaSelect, 8-Anthem 9-Delta Dental)*IF 2 INSURANCES, LEAVE AS FEE SCHED. 1  Billing type selected (1-Regular, 2-Superior, 12-Aetna (&Aetna Vital Savings), 11-DentaSelect, 7-Ortho, 13- Anthem 14 Delta Dental) *UNLESS THEY HAVE 2 INSURANCES (or Anthem Federal)-THEN LEAVE AS BILLING TYPE 1  Aetna Vital Savings patients need a flag that they are managed care with no additional discounts but they do not have insurance  Entered employer & insurance benefits into Dentrix  Confirmed benefits used (other offices) $______ Called insurance company & confirmed benefits  Get X-ray history from insurance  Patient aware of their portion due after insurance  First visit date changed