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Patient Intake Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Preferred Method of Contact

If you are completing this form for another person, what is your relationship to that person?

Dental Information

Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you ever had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Do you have earaches or neck pains?
Do you have any clicking, popping, or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Are you currently experiencing dental pain or discomfort?

Medical Information

Are you currently under the care of a physician?
Are you in good health?
Has there been any change in your general health within the past year?
Do you have a history of chemical dependency?
Are you in recovery?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Do you take any blood thinners?
Do you take aspirin on a regular basis?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Women Only Are you:

Pregnant?
Taking birth control pills or hormonal replacements?
Nursing?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever / seasonal
Animals
Food / Other

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systematic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer / Chemotherapy / Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or type II
Eating disorder
Malnutrition
Gastrointestinal disease
GE Reflux / persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice, or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
Recurrent infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches / migraines
Severe / rapid weight loss
STDs / STIs
Excessive urination
ADD
ADHD
Sensory Processing Disorder
Oral Sensory Sensitivity
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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HIPAA Consent Form

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Patient Screening Form

General Information

Patient Screening

Have you/they recently been vaccinated for COVID-19?
Have you/they recently received a booster shot for COVID-19?
Have you/they recently been tested for COVID-19?
Have you/they tested positive for COVID-19?
Within the past 14 days, have you/they had a known exposure to any individual suspected or confirmed to have COVID-19 or who has traveled to a location after which self-quarantine is recommended?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Within the past 24 hours, have you/they had any of the following symptoms?

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headaches
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Insurance Form

General Information

Primary Dental Insurance

Policy Holder
Relationship to Patient

Secondary Dental Insurance

Policy Holder
Relationship to Patient

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

I give my consent for examination and treatment.

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information may be released to

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Broken Appointments Form

It is extremely important to keep your appointment for your dental treatment since there will be an hour of the Doctor’s time scheduled exclusively for you. Caring Bear Dental is now charging a 50 Dollar Broken appointment fee for any treatments scheduled that are not Cancelled or Rescheduled on time. If you are unable to come in, please call our office at 818-284-4155 to cancel or reschedule your appointment at least 24-48 hours prior your appointment. Our office provides the opportunity to confirm your appointments by calling or texting our office one day before your scheduled appointment, please confirm your attendance by calling or texting us back before 3 PM. Otherwise your appointment may be cancelled in order to provide service to other patients in need of an appointment.

We thank you in advanced for your appreciation and respect of the Doctor’s time.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Insurance Responsible Party

Like most dental offices, we’ll file your claim with your insurance in lieu of expected payments to be paid to our office. However, Caring Bear Dental cannot and will not hold an insurance company or employer as the responsible party. The patient, or parent if the patient is a minor, is directly responsible for all payments to be made to Caring Bear Dental including all co-payments and deductibles.

Please note that co-payments made by you are merely an estimation, as we don’t know the exact amount your insurance company will pay. The remainder of your balance will be collected once payment is received from your insurance company. If your insurance company refuses to pay, you acknowledge responsiblity for full payment of the bill and agree to do so within 30 days of service.


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue