Let us see those pearly whites

We are excited you have chosen to become a patient! We need to get to know you a little more, please complete our new patient form. You can submit the form by either:

Download the form here in Adobe PDF format, complete and bring with you to your appointment

 

-OR-

 

Complete the online form below and submit when completed

Online Patient Information Form

 PATIENT INFORMATION 

Marital Status:

 EMERGENCY CONTACT 

 DENTAL INSURANCE 

Is patient covered by additional insurance?

ASSIGNMENT & RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

and

assign directly to Dr.

all insurance benefits, if any, otherwise payable to me

for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the

above-named Insurance Company(ees) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

 DENTAL & 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 pertaining both your dental and medical history.

PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:

Bad breath
Bleeding gums
Blisters on lips or mouth
Cigarette, pipe or cigar smoking
Clicking or popping jaw
Dry mouth
Burning sensation on tongue
Fingernail biting
Chew on one side of mouth
Food collection between teeth
Foreign objects
Lip or cheek biting
Orthodontic treatment
Sensitivity to heat
Grinding teeth
Loose teeth or broken fillings
Pain around ear
Sensitivity to sweets
Gums swollen or tender
Mouth breathing
Periodontal treatment
Sensitivity when biting
Jaw pain or tiredness
Mouth pain, brushing
Sensitivity to cold
Sores or growths in your mouth
Women, are you:
Are you allergic to any of the following:
Are you under a physician's care now?
Are you taking any pills, medication or drugs?
Are you on a special diet?
Have you ever been hospitilized or had a major operation?
Do you take, or have taken, Phen-Fen or Redux?
Have you ever had a serious head or neck injury?
Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?
Do you use tobacco?
Do you use controlled substances?

DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?

AIDS/HIV Positive
Alzheimer's Disease
Anphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Pressure
Blood Transfusion
Breathing Problems
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 Pacemaker
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
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
Tonsillits
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above?

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, Guardian or Personal Representative

 NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT & PATIENT CONSENT FORM 

I understand, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health/dental information. I understand this information can and will be used to:

  • Conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in my treatment directly and/or indirectly.

  • Conduct normal healthcare operations, such as physician certifications and assessments.

  • Obtain payment from third party payers, such as insurance companies.

  • Confirm and leave messages at phone numbers provided to this office.

I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at anytime to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or dental care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions.

Signature

Reach out to us

Dr. Alan K. Mauldin, D.D.S.

420 S. Mustang Road

Yukon, Oklahoma 73099

Phone: (405) 324-0200

Fax: (405) 324-0225

Office Hours:

Monday-Wednesday 8 a.m. to 1 p.m. and 2 p.m. to 5 p.m.

Thursday 8 a.m. to 3 p.m.

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© 2010-2020 by Dr. Alan Mauldin, DDS, PLLC. Designed and Developed by The Guild