New Patient Form

Name
First Last
Birthdate
Month
Day
Year
Social Security Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Email
Your preferred method of contact
- Text
- Email
Check all that apply
- Male
- Female
- Married
- Separated
- Divorced
- Single
- Widowed
Who can we thank for referring you?
Date of last dental exam
Month
Day
Year
Date of last x-rays
Month
Day
Year
Emergency Contact Name
First Last
Emergency Contact Phone
Name
First Last
Responsible Party
Is the responsible party different from the patient?
- Yes
- No
Name of ther person responsible for this account
Birthdate
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Name of policy holder
First Last
Relationship to Patient
- Self
- Spouse
- Child
- Other
Birthdate of Policy Holder
Month
Day
Year
Insurance Company
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Group Name (if applicable)
Group Number
Subscribe ID Number or SSN Number
Please initial to show that you have read and agree to the statements below:
Monthly Statements

Each month you will receive a statement showing your current balance. After 60 days your account will have incurred a Finance Charge at 1-1/2% interested added each month.
Return Check Policy

You may able charged a service charge of $20 for any check not honored as payment on your account.
Attorney Fees and Costs

If we are forced to take collection action or any other legal action on your account, you agree to pay all court and collection costs and reasonable attorney's fees.
Information Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment of examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants. Please Initial
Attorney Fees and Cost

If we are forced to take collection action or any other legal action on your account, you agree to pay all court and collection costs and reasonable attorney's fees.
Diagnostic Procedures

I consent to the Diagnostic procedures and treatment by the dentist necessary for proper dental care
Excluded Insurances
- Yes
- No
We are not contracted to take any new patients with True Blue, Idaho Smiles, or Medicaid. Are you insured by any of these companies?
HIPAA

I have been given the opportunity to read the notice of privacy practices containing a more complete description of the uses and disclosures of my personal health information. Rockhouse Dentistry is authorized to release and/or request information that may be necessary for either treatment or billing purposes. The following family members are authorized to receive personal health information from this office:
Authorized Family Members
Are you under a physicians care now?
- Yes
- No
Have you ever had a serious head or neck injury?
- Yes
- No
Do you take, or have you taken, Phen-Fen or Redux?
- Yes
- No
Are you on a special diet?
- Yes
- No
Have you ever been hospitalized or had a major operation?
- Yes
- No
Are you taking any medications, pills, or drugs?
- Yes
- No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
- Yes
- No
Do you use tobacco?
- Yes
- No
Do you use controlled substances?
- Yes
- No
Women: Are you
- Pregnant/Trying to Get Pregnant
- Nursing
- Taking Oral Contraceptives
Are you allergic to any of the following?
- Aspirin
- Acrylic
- Local Anesthetics
- Penicillin
- Metal
- Sulfa Drugs
- Codeine
- Latex
- Other
Please explain your allergy
Do you have, or have you had, any of the following?
- AIDS/HIV Positive
- Alzheimer's Disease
- Anaphylaxis
- Anemia
- Angina
- Arthritis/Gout
- Artificial Heart Valve
- Artificial Joint
- Asthma
- Blood Disease
- Blood Transfusion
- Breathing Problem
- Bruise Easily
- Cancer
- Chemotherapy Chest Pains
- Cold Sores/Fever Blisters
- Congenital Heart Disorder
- Convulsions
- Cortisone Medicine
- Diabetes
- Drug Addiction
- Easily Winded
- Emphysema
- Epilepsy or Seizures
- Excessive Bleeding
- Excessive Thirst
- Fainting Spells/Dizziness
- Frequent Cough
- Frequent Diarrhea
- Frequent Headaches
- Genital Herpes
- Glaucoma
- Hay Fever
- Heart Attack/Failure
- Heart Murmur
- Heart Trouble/Disease
- Hemophilia
- Hepatitis A
- Hepatitis B or C
- Herpes
- High Blood Pressure
- High Cholesterol
- Hives or Rash
- Hypoglycemia
- Irregular Heartbeat
- Kidney Problems
- Leukemia
- Liver Disease
- Low Blood Pressure
- Lung Disease
- Mitral Valve Prolapse
- Hemophilia
- Osteoporosis
- Pain in Jaw Joints
- Parathyroid Disease
- Psychiatric Care
- Radiation Treatments
- Recent Weight Loss
- Renal Dialysis
- Rheumatic Fever
- Rheumatism
- Scarlet Fever
- Shingles
- Sickle Cell Disease
- Sinus Trouble
- Spina Bifida
- Stomach/Intestinal Disease
- Stroke
- Swelling of Limbs
- Thyroid Disease
- Tonsillitis
- Tuberculosis
- Tumors or Growths
- Ulcers
- Venereal Disease
- Yellow Jaundice
Have you ever had any serious illness not listed above?
- Yes
- No
Cancelation Notice*
I Agree
If you are unable to keep your appointment, notify us as soon as possible. Any patient that misses an appointment without 24 hours' notice may be charged a $100 fee.
Monthly Statement*
I Agree
Statements will be sent monthly showing your current balance. After 90 days, your account will incur a Finance Charge at 18% annual interest.
Electronic Signature

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN
Today's Date
MM slash DD slash YYYY

Contact Info

Phone:
208-356-5600
Email:
rockhousedentistry@hotmail.com
Address:
106 E. 1st North
Rexburg, ID 83440

Hours of Operation:

Monday: 8am - 5pm
Tuesday: 8am - 5pm
Wednesday: 8am - 5pm
Thursday: 8am - 5pm
Fridays: 9am - 2pm

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