Call Today : 602.714.2223
4202 N. 32nd Street, Suite B, Phoenix, AZ 85018 | Directions

Online Patient Form

We warmly welcome you to our office. Please take a few moments to complete the following information so that we can better care for you. It is our goal to help you to achieve the smile you have always wanted. All information is transmitted over a secure server to ensure all your information remains protected and confidential.
Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Information

Patient Name :
Last Name*
First Name*
Middle Name
Prefer to be called : Sex : Male Female
Your birthday:*
(We need this to verify your dental benefits)
Home Address: City
State Zip
Home Phone:* ()--
Work Phone: ()---
Cell Phone : ()--
How do you prefer to confirm your appointments? Phone call Text Email
Employer : Occupation :
How did you hear about us?
Whom may we thank for referring you?
Other family members seen by us?
Prev/Present dentist :
Date of last visit :
Phone Number: ()--
In the event of an emergency, is there someone who lives near you that we should contact?
Contact Person: Relationship:
Home Phone: ()--
Work Phone: ()---

Dental Insurance Information

Primary Dental Insurance
Insurance co. name :
Address : City
State Zip
Telephone: ()--
Group No:
Insured’s Name: Relationship:
Date of Birth:
Secondary Dental Insurance
Insurance co. name :
Address : City
State Zip
Telephone: ()--
Group No:
Insured’s Name: Relationship:
Date of Birth:
A note for patients with dental insurance – We will assist you to maximize your insurance benefits, and we are happy to file claims to your insurance carrier and agree to accept payment from any carrier that offers an assignment of benefits, if you desire. We will do our best to calculate your available benefit amount, however, regardless of what your insurance plan pays, you are responsible for all fees.

Medical History

Your current physical health is : Good Fair Poor
Are you currently under the care of a physician? Yes No
Please explain :
Are you taking any prescription/over the counter drugs? Yes No
Please list :
Do you need antibiotic pre-medication prior to a dental visit? Yes No
Do you use or smoke tobacco in any form? Yes No
For women: Are you taking birth control pills? Yes No
Are you pregnant?     Week #:  Yes No
Are you nursing? Yes No
Have you ever had any of the following diseases or medical problems?
Yes No Abnormal bleeding Yes No Alcohol/drug abuse
Yes No Anemia Yes No Arthritis
Yes No Artificial bones/joints/valves Yes No Asthma
Yes No Blood transfusions Yes No Cancer/chemotherapy
Yes No Colitis Yes No Congenital heart defect
Yes No Diabetes Yes No Difficulty breathing
Yes No Emphysema Yes No Epilepsy
Yes No Fainting spells Yes No Frequent headaches
Yes No Glaucoma Yes No Hay fever
Yes No Heart attack Yes No Heart murmur
Yes No Heart surgery Yes No Hemophilia
Yes No Hepatitis Yes No Herpes/fever blisters
Yes No High blood pressure Yes No Hiv+/Aids
Yes No Hospitalized any reason Yes No Kidney problems
Yes No Latex allergy Yes No Liver disease
Yes No Low blood pressure Yes No Mitral valve prolapse
Yes No Nervous/anxious Yes No Pacemaker
Yes No Psychiatric problems Yes No Radiation treatment
Yes No Rheumatic/scarlet Fever Yes No Seizures
Yes No Shingles Yes No Sickle cell disease
Yes No Sinus problems Yes No Stroke
Yes No Thyroid problems Yes No Tuberculosis
Yes No Ulcers Yes No Venereal disease
Please list any other serious medical condition(s) that you have ever had:
Are you allergic to any of the following items?
Yes No Aspirin Yes No Codeine Yes No Dental anesthetics
Yes No Erythromycin Yes No Latex Yes No Penicillin
Yes No Tetracycline Yes No Other
Please list any other drugs you are allergic to:

Dental History

Many patients consult us for a 2nd opinion. Are you currently seeing another dentist for your dental needs? Yes No
Please explain :
How would you describe the condition of your teeth and gums? Good Fair Poor
How often do you: Brush your teeth? Floss?
Do your gums bleed when you brush or floss? Yes No
Have you ever experienced pain in your jaw joint? Yes No
Have you ever been treated for TMJ symptoms? Yes No
Please explain :
Do you wake up with headaches? Time/Week:  Yes No
Do you get headaches during the day? Time/Week:  Yes No

* I understand that this information is correct to the best of my knowledge. I understand it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.
* I authorize the doctor and his staff to perform any necessary dental services that I may need during the diagnosis and treatment of my dental condition. I understand that Dr. Koppikar is adjunct faculty at the Arizona School of Dentistry and I give him and his office permission to use any photos taken for lecturing, publishing, educational, or promotional purposes.
* If I cannot make my appointment I will call the office 24 hours in advance or there will be a $50.00 per missed hour fee.
* I understand payment is due in full at the time of treatment.

*Signature of Responsible Party

Getting to know you ....

Welcome to Biltmore Dental Center- we welcome you to our dental family!
Let us get acquainted…
Hobbies & Interests:
Family? Children? Pets? … (ages)
Today’s dentistry allows us to enhance your smile quickly and easily. How would you like your smile to look? (circle all that apply)
Straighter Whiter Shorter Wider
Longer More Even Close Spaces Replace Partials / Dentures
Fresher Breath Replace Missing or Cracked Teeth
Other Reasons for today’s visit:
When would you like to begin?

Financial Agreement

Thank you for choosing us as your health care provider. We are committed to your treatment success.

Regarding Insurance

- We require deductible and co pays to be paid at the time of service.
- We accept: Cash, Checks and Credit cards (MC, Visa, AmEx, Discover)
- Your insurance policy is a contract between you and your insurance company. However, we will automatically bill your insurance company for services rendered as a courtesy to you.
- If your insurance company has not paid the total claim within 90 days from the date of your treatment, the balance will automatically be billed to you. Please be aware that we may receive only a partial amount of what was totally billed to your insurance company. You will be responsible for amounts the insurance company has determined as ineligible or not covered in full.
- If we cannot verify eligibility prior to treatment, you are expected to pay in full at the time of service. We will be glad to submit your insurance form and direct your insurance company to make payment directly to you.

Usual And Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
Thank you for understanding our Financial Agreement. Please let us know if you have any questions or concerns.
* I have read and understand the Financial Agreement.

*Signature of Responsible Party

Acknowledgement Of Receipt Of Notice Of Privacy Practices

(This document is available on our website – or you can request a copy in our office)
**You May Refuse to Sign This Acknowledgement**
I have received a copy of this office’s Notice of Privacy Practices.
Thank you for your time.

Signature of Responsible Party Date