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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:*

SSN:*

(We need this to verify your dental benefits)

Home Address:					City
	State		Zip		Apt#

Home Phone:*	()--	Work Phone:	()---
Cell Phone :	()--	E-mail:*
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		Apt#

Telephone:

()--

Group No:

Insured’s Name:

Relationship:

Date of Birth:

SSN:

Secondary Dental Insurance

Insurance co. name :

Address :					City
	State		Zip		Apt#

Telephone:

()--

Group No:

Insured’s Name:

Relationship:

Date of Birth:

SSN:

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	Date

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	Date

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

Dental Patient Information Phoenix - Patient reviews for Dr. Sameet Koppikar on Dr. Oogle

Dr. Sameet Koppikar is rated #1
out of 330 Phoenix dentists

based on 286 reviews

Phoenix Dentist - for Dr. Sameet Koppikar winner of Talk of the Town Award 2014

Biltmore Dental Center
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Dr. Sameet Koppikar, DDS has been recognized as one of the top Phoenix Dentistry practices. Verified by Opencare.com

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Dr. Koppikar has been named a Top Phoenix Cosmetic Dentist in the Consumers' Research Council of America's Guide to America's Top Dentists.

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Online Patient Form

Patient Information

Dental Insurance Information

Medical History

Dental History

Getting to know you ....

Financial Agreement

Regarding Insurance

Usual And Customary Rates

Acknowledgement Of Receipt Of Notice Of Privacy Practices