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Call: (515) 224-5999
1089 Jordan Creek Parkway,
Suite 100, West Des Moines, IA 50266

New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title : MrMrsMsDr
*Last name :
Middle name : *First name :
I prefer to be called : Sex : MaleFemale
*Your birthday :
Social security # :
*Home address :
*Email address :
Marital Status : SingleMarriedPartneredDivorced / SeparatedWidowed
Telephone :
*Home : ()--
Work : ()---
Cell : ()--
Driver’s license number :
Employer :
Employer address :
City State
How long there ? Occupation :
Where & when are best times to reach you?
How did you hear about us? Have you visited our website? YesNo
Whom may we Thank for referring you?
Other family members seen by us :
Previous dentist : Present dentist :
Last Visit Date :
Spouse information
His / Her name : Employer :
Birthday :
Social security # :
Driver’s license number : Telephone work : ()---
Person Responsible for Account:
Telephone :
Home : ()--
Work : ()---
Employer address :
Relationship : Social security #:
Employer : Driver’s license number :
Insurance information
Primary insurance
Insurance Co. name:
Address :
Phone : ()--
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
Social security # :
Insured’s employer :
Address :
Secondary insurance
Insurance Co. name :
Address :
Phone : ()--
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
Social security # :
Insured’s employer :
Address :
In the event of an emergency, is there someone who lives near you that we should contact?
His / Her Name : Relation :
Home phone : ()--
Work phone : ()---
Dental History
What is the reason for your visit today?
How do you consider your current dental health? GoodFairPoor
Do you like your smile? YesNo
Are you happy with the color of your teeth? YesNo
Do your gums bleed? YesNo
How many times a day do you brush? Floss?
How long do you use a toothbrush before replacing it?
What type of toothbrush bristles do you use? HardMediumSoft
Are your teeth sensitive to HeatCold
Do you have any fears of dental visits? YesNo If so, what are they?
When was your last dental cleaning?
Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician’s care now? Yes No If yes, Please explain
Have you ever been hospitalized or had a major operation? Yes No If yes, Please explain
Have you ever had a serious head or neck injury? Yes No If yes, Please explain
Are you taking any medications, pills or drugs? Yes No If yes, Please explain
Do you take, or have you taken, Phen-Fen or Redux? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No
Women : Are youPregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?
Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other
Please explain :
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer’s Disease
Artificial Heart Valve
Artificial Joint
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Drug Addiction
Easily Winded
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hepatitis A
Hepatitis B or C
High Blood Pressure
Hives or Rash
Irregular Heartbeat
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tumors or Growths
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above? Yes No If yes, Please explain
* I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

A 1.5% service charge will be added to all past due balances. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

Payment is due in full at the time of treatment unless prior arrangements have been approved. Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CBC and the ADA.

Insurance Guidelines

Welcome to Plaza Dental Group! We are delighted that you have chosen our office to care for your teeth. Our goal is to treat patients of all ages with different needs and we use our best efforts to make your experience as pleasant as possible.
Please be aware that even if you have dental insurance, your account with Plaza Dental Group is your responsibility, NOT that of your insurance company. Before or during your initial visit, we call your insurance company to obtain your benefit information. The insurance company's representative immediately reads us a disclaimer which explains that they do not guarantee payment of your account, and that payment by them is based on a percentage (as indicated by your policy - e.g., 80%, 90%, etc.) of what your insurer considers "usual and customary" fees. We urge you to be fully aware of the provisions of your policy, as we are NOT responsible for any errors, omissions, or misinformation provided to us by your insurance company. The estimated amount of the fees for which you are responsible is collected on the date of service. This estimated amount is only an estimate, and is not certain to be the total amount for which you are responsible. Some insurance companies "downcode" the procedures performed, meaning that the insurance company's reviewer determines that the degree of difficulty of the treatment is less than what was performed. When your insurance company downcodes, your insurance company pays less on your claim. We are most willing to appeal such a decision per your request. Although we do our best to provide the most accurate information to you, it is possible that you may still owe on your account after your insurance company has remitted payment. We ask that the balance be paid upon receipt of your billing statement.
Please feel free to call us with any questions. We look forward to working with you and will do our best to meet your needs.
Thank you,
Plaza Dental Group
*I acknowledge that I have received, read, and understand the above Insurance Guidelines.
*Signature :
Date :