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Reed Chiappetti, DDS
Rasha Ahmad, DMD
Our Staff
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Dental Crowns
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Teeth Whitening
More Cosmetic Services
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Dental Veneers
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More Restorative Services
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Invisalign Braces
More Orthodontic Services
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Sedation Dentistry
Emergency Dentistry
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Bleeding Gums
Gingivitis
Gum Disease
Gum Infection
Periodontitis
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More Gum Conditions
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Bruxism
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More Jaw Conditions
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Dry Mouth
Mouth Sores
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Smile Correction
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Enamel Erosion
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New Patient Form
Complete the form below
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4
25%
Patient Information
Name
*
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MI
Last
Date
*
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*
-- Select --
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Other
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Referral Information
Who Is Your
General Dentist
?
*
Whom May We Thank For Referring You To Our Practice?
*
In case of an emergency who may we call?
Name
*
Relationship
*
Phone
*
Employment Information
Employer Name
*
Occupation
*
Employer Phone
*
Insurance Information
Are You Insured?
*
Yes, I Know My
Insurance
Info
Yes, I Don't Know My Insurance Info
No, I Will Pay Out Of Pocket
Other
Explain:
Primary
Name of Insured
First
MI
Last
Insured's Birth Date
ID #
Group #
Insured's Employer Name
Patient's relationship to insured
Self
Spouse
Child
Other
Secondary
Name of Insured
First
MI
Last
Insured's Birth Date
ID #
Group #
Insured's Employer Name
Patient's relationship to insured
Self
Spouse
Child
Other
Medical
Name of Insured
First
MI
Last
Insured's Birth Date
ID #
Group #
Insured's Employer Name
Patient's relationship to insured
Self
Spouse
Child
Other
Health Information
Date of Last Dental Visit
*
Reason for your visit today
*
Have you ever had any of the following?
AIDS
*
Yes
No
Allergies
*
Yes
No
Anemia
*
Yes
No
Angina
*
Yes
No
Arthritis
*
Yes
No
Artificial Joints/Implants
*
Yes
No
Asthma
*
Yes
No
Blood Disease
*
Yes
No
Cancer
*
Yes
No
Chronic Cough
*
Yes
No
Clicking/Popping of Jaw
*
Yes
No
Depressed Immune System
*
Yes
No
Diabetes
*
Yes
No
Dizziness
*
Yes
No
Emphysema
*
Yes
No
Epilepsy
*
Yes
No
Excessive Bleeding
*
Yes
No
Fainting
*
Yes
No
Glaucoma
*
Yes
No
Grind or Clench Teeth
*
Yes
No
Hay Fever
*
Yes
No
Heart Attack
*
Yes
No
Heart Surgery
*
Yes
No
Heart Palpitations
*
Yes
No
Heart Valve
*
Yes
No
Head Injuries
*
Yes
No
Heart Disease
*
Yes
No
Heart Murmur
*
Yes
No
Hepatitis
*
Yes
No
High Blood Pressure
*
Yes
No
HIV
*
Yes
No
Jaundice
*
Yes
No
Kidney Disease
*
Yes
No
Liver Disease
*
Yes
No
Lung Disease
*
Yes
No
Mental Disorders
*
Yes
No
Nervous Disorders
*
Yes
No
Osteoporosis
*
Yes
No
Pacemaker
*
Yes
No
Currently Pregnant
*
Yes
No
Currently Nursing
*
Yes
No
Radiation Treatment
*
Yes
No
Respiratory Problems
*
Yes
No
Rheumatic Fever
*
Yes
No
Rheumatism
*
Yes
No
Seizures/Convulsions
*
Yes
No
Sinus Problems
*
Yes
No
Stomach Problems
*
Yes
No
Stroke
*
Yes
No
Thyroid Disease
*
Yes
No
Tuberculosis
*
Yes
No
Tumors
*
Yes
No
Ulcers
*
Yes
No
Venereal Disease
*
Yes
No
Other
*
Yes
No
Please list other(s):
Do you need to PreMedicate prior to Dental Appointment?
*
Yes
No
Other
Are you using any of the following?
Antibiotics
*
Yes
No
High Blood Pressure
*
Yes
No
Medication
*
Yes
No
Blood Thinners
*
Yes
No
Steroids/Cortisone
*
Yes
No
Heart Drugs (Digitals/Inderal etc.)
*
Yes
No
Aspirin / Motrin, Aleve
*
Yes
No
Ibuprofen
*
Yes
No
Phen Phen
*
Yes
No
Tranquilizers
*
Yes
No
Insulin / Anti-Diabetic Drugs
*
Yes
No
Please list any other medications you are taking including prescription medications, diet drugs, over-the-counter medications, herbal or hollistic remedies, vitamins or minerals
*
Have you ever used any of the following?
Biosphosphnates (for Oseoporosis/Cancer)
*
Yes
No
Fosamax, Actonel, Boniva, Aredia, or Zometa
*
Yes
No
Phen-Phen
*
Yes
No
Are you allergic to or have you had an adverse reaction to any of the following?
Local Anesthesia/ Novocaine
*
Yes
No
Penicillin / Antibiotics
*
Yes
No
Sedatives / Barbiturates
*
Yes
No
Aspirin/ Ibuprofen
*
Yes
No
Codeine/ Pain killers
*
Yes
No
Latex/Rubber
*
Yes
No
Other
*
Yes
No
Have you ever had any complications following dental treatment?
*
Yes
No
Please explain
Do you smoke or chew Tobacco products?
*
Yes
No
How much per day?
Have you ever had past history of Alcohol, Chemical dependency or Emotional disorder?
*
Yes
No
Have you or an immediate family member ever had any problems associated with intravenous anesthesia?
*
Yes
No
Please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
*
Yes
No
Please explain:
Are you now under the care of a physician?
*
Yes
No
Please explain:
Physician Name
Physician Phone
Do you have any health problems that need further clarification?
*
Yes
No
Please explain:
If you are using oral contraceptives, it is important to understand that antibiotics (and some other medications) may Interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control.
Do you wish to talk to the doctor privately about anything?
*
Yes
No
Please explain:
Acknowledgement
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature (Initials)
*
Date
*
Almost done! Please read the following carefully, initial each statement and sign below. Clicking Submit will send the new patient form to Imagine Dental. Thank you for your time.
Consent For Services
In the event that I was to swallow or aspirate a dental restoration such as a filling,
crown
, onlay, inlay, veneer,
bridge
, and implant etc… I will agree to have an x-ray taken at a healthcare facility of my choice to rule out any possible complications. Imagine Dental has agreed to pay for this procedure. If I chose to decline the x-ray, I agree to sign a waiver and will not hold Imagine Dental liable for any and all future health related issues caused by the event.
If your doctor prescribes any medication for you, understand it may cause drowsiness and you should not drive, operate heavy machinery, or sign important legal documents while taking that drug. Please consult your doctor if you have any questions.
Imagine Dental will not be held responsible for any valuables brought into the operating room suites. Please arrange for these items to be cared for by someone else while you are being treated.
Thank you for choosing Imagine Dental, this policy was designed to ensure that all finances (payments due) are recovered, which will allow us to continue to provide the best quality dental care for our patients. It is important to keep patient/office relationship strong, therefore it is important to assure payment for services is a smooth transaction by making it as simple and straight forward as possible.
Initials
Payment is expected at the time services are provided. If patient has insurance, the estimated patient portion is due at the time of service. Any payment arrangement must be made in advanced.
*
Imagine Dental allows 45 days for insurance company to pay the insurance estimated portion. If insurance has not fully paid a claim after allowed time, patient is expected to pay the remaining portion.
*
As a courtesy to our valued patients, Imagine Dental verifies patient’s benefits and generates claim charges to insurance company. Information received is NOT a guarantee of payment, benefits received are used to estimate patient financial portion.
*
Patient understands that any costs incurred during treatment are patient responsibility. Insurance may help pay for a portion of treatment. Treatment quoted is an ESTIMATE only. Patient will be responsible for any unpaid fees by insurance company.
*
A 1.8% interest may applied to the balance and additional costs of balance being sent to a collection agency (30% or greater) will be applied to the balance. Patient will be responsible for any legal fees.
*
Due to a high demand for appointment, missed appointments prevent us from scheduling appropriately and keep others in needs of urgent care from being seen. A $50.00 fee will be assed for all missed appointments not cancelled with 48 hour notice
*
Permission
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content.
I hereby acknowledge that I have reviewed a copy of this practice's
Notice of Privacy Practices
. I have been given the opportunity to ask any questions I may have regarding the Notice.
Patient Printed Name
*
Patient Signature (Initials)
*
Patient Date
*
Delivery
Where would you like to send this form?
*
-- Select --
Ahwatukee Office
Phoenix Office
Name
This field is for validation purposes and should be left unchanged.
Close Menu
About Us
Why Choose Us?
Our Doctors
Reed Chiappetti, DDS
Rasha Ahmad, DMD
Our Staff
Health & Safety
Technology
Affordability
FAQs
Services
Cosmetic Dentistry
Dental Crowns
Dental Veneers
Teeth Cleaning
Teeth Whitening
More Cosmetic Services
Restorative Dentistry
Dental Bridges
Dental Crowns
Dental Fillings
Dental Implants
Dental Veneers
Dentures & Partials
Root Canals
More Restorative Services
Orthodontics
ClearCorrect Braces
Invisalign Braces
More Orthodontic Services
Periodontics
Sedation Dentistry
Emergency Dentistry
More Services
Conditions
Gums
Bleeding Gums
Gingivitis
Gum Disease
Gum Infection
Periodontitis
Receding Gums
More Gum Conditions
Jaw
Bruxism
TMJ
More Jaw Conditions
Mouth
Bad Breath
Dry Mouth
Mouth Sores
Oral Cancer
Smile Correction
More Mouth Conditions
Teeth
Cavities
Crooked Teeth
Enamel Erosion
Hyperdontia
Missing Teeth
Stained Teeth
Toothaches
More Teeth Conditions
More Conditions
New Patients
Download Forms
Fill Out Forms
Patient Testimonials
Accepted Insurance
Discount Dental Plan
Contact
Contact Us
Ahwatukee Location
Phoenix Location
Appointments
Blog
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