New Patient Form Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.Step 1 of 1010%Select Office Location*GreshamPortlandVancouver - Mill PlainVancouver - Tech CenterOffice Location and InformationYour inquiry will be sent to the following location: Address: 1700 NW Civic Dr #320 Gresham, OR 97030 Phone: (503) 666-5200Office Location and InformationYour inquiry will be sent to the following location: Address: 5071 NE 122nd Ave Portland, OR 97230 Phone: (503) 255-5700Office Location and InformationYour inquiry will be sent to the following location: Address: 12116 SE Mill Plain Blvd #3 Vancouver, WA 98684 Phone: (360) 256-8200Office Location and InformationYour inquiry will be sent to the following location: Address: 16600 SE 15th St Vancouver, WA 98683 Phone: (360) 828-7435Patient InformationName* First Middle Last I prefer to be called Sex*MaleFemaleAge*Date of Birth (mm/dd/yyyy)* Marital Status*SingleMarriedDivorcedWidowedEmail Address* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer's NameEmployer's PhonePlease tell us where you heard about us*Other family members treated by usAdditional Comments Emergency ContactThis should be the nearest relative who does not live with the patient.Name* First Last Relationship to Patient Phone* Insurance InformationDo you have insurance?NoYesPrimary InsuranceInsurance Holder's NameDate of Birth (mm/dd/yyyy) Relationship to PatientEmployerMember IDGroup IDInsurance Company NameInsurance Company PhoneInsured's SSNSecondary InsuranceDo you have secondary insurance?NoYesInsurance Holder's NameDate of Birth (mm/dd/yyyy) Relationship to PatientEmployerMember IDGroup IDInsurance Company NameInsurance Company PhoneInsured's SSN AuthorizationAll of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Columbia River Dentistry to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to Columbia River Dentistry. I permit a copy of this authorization to be used in place of the original. I give Columbia River Dentistry, its employees, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.Signature (Type your name to sign electronically, or print and sign)*Date (mm/dd/yyyy)* Consent for Treatment I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient. Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I have read, understood, and agree to the above treatment policy.Patient Name*Signature (Type your name to sign electronically, or print and sign)*Date (mm/dd/yyyy)* Would you like to discuss our office's financial policy?*YesNo Payment PoliciesPayment is due at the time of service unless alternative arrangements have been made in advance. Thank you for taking the time to understand our payment policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our office staff for clarification. We accept cash, cheque, card and work with care credit for your convenience.For Patients with Dental InsuranceWe accept dental insurance assignments, with the understanding that any uninsured portion not covered by your insurance plan is to be paid by you at the time of service. As a courtesy, our office will file all applicable insurance forms. Please note that although we strive to provide accurate information, such information is not a guarantee of payment or eligibility with your insurance company and is only an estimate. Your dental insurance plan is a contract between you, your employer, and the insurance company. Depending on your specific insurance plan, your dental insurance may not fully cover our office dental fees for the services we render. The difference between our office dental fees and your insurance reimbursement is your responsibility.Returned ChecksPersonal checks that are returned due to "insufficient funds" are subject to a $25.00 service fee.Service ChargePayment is due at each appointment. I agree to pay any outstanding insurance balance within 60 days. If I do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1.5% per month (or a minimum charge of $2.50 for a minimum balance of $25.00) which is an annual percentage rate of 18% applied to the last month's balance. In case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account balance or any future accounts. Please be advised that there is a $50.00 fee charged for missed or broken appointments without 24 hours notice. To avoid this charge, kindly give us a minimum of 24 hours notice for any appointment cancellation. Feel free to contact us at any time with questions you may have.X-Ray/Records ReleaseThere is a fee of $25.00 for any release of X-rays and/or records.MinorsAdult patients are responsible for full payment at time of service. The adult accompanying a minor is responsible for payment. This office will not bill a non-custodial parent for services delivered to a minor. For unaccompanied minors, treatment may be denied unless charges have been pre-approved to a credit card or other payment arrangements have been madeAuthorizationI hereby authorize payment directly to Columbia River Dentistry of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of the above-named patient's dental treatment. The information on the page and the dental/medical histories are correct to the best of my knowledge. I grant the right to Columbia River Dentistry to release the patient's dental and/or medical histories and other information about the patient's dental treatment to third-party payers and/or other health professionals.Patient Name*Signature (Type your name to sign electronically, or print and sign)*Date (mm/dd/yyyy)* Dental HistoryWould you like to give us your previous dentist's contact info?NoYesPrevious DentistDentist NameDental Practice NamePhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Today's VisitWhat is the purpose of today's visit? Dental ConcernsCheck all that apply.Teeth* None Broken or chipped Crooked Decay Difficulty chewing Discolored Loose/missing filling Loose teeth Tooth pain Food trap areas Grinding or clenching Missing teeth Mouth sores Sensitive to cold Sensitive to heat Sensitive when biting Sensitive to sweets Blisters on lips/mouth Orthodontic treatment Bad taste in mouthGums* None Bad breath Red (discolored) Abcessed Bleeding Sore Swollen Receding Periodontal treatmentFacial/Jaw Pain* None Frequent headaches Pain in temples Pain in jaw Jaw injury Head injury Neck injury Pain around earOther Concerns* None Smoking/dipping Biting cheeks or lip Popping/clicking Tooth-colored fillings Wisdom teeth Sleep apnea Jaw locks open/closed Chew on one side Snoring Retainer Dry mouth Cosmetics Smile makeover Dental phobiasHave you ever had:Check all that apply. None Orthodontic treatment Oral surgery Any canker sores or cold sores on your lips, tongue, gums, or body Periodontal treatment Your bite adjusted A bite plate or mouth guard A serious injury to the mouth or head? If yes, please describe including cause:Please describe Medical HistoryHow is your general health?*GoodFairPoorAre you currently under medical treatment? If yes, what for?NoYesPlease provide details:Do you require antibiotic pre-medication for your dental work? If yes, what for?NoYesPlease provide details:Physician's NamePhoneDo we have permission to contact your doctor regarding your care?*YesNoHave you ever had:Check all that apply.* None Arteriosclerosis Cancer Head or face injury Heart murmur/trouble History of substance abuse/drug addiction Kidney problems Numbness of arms or hands Allergies Asthma Blood disease Diabetes Intestinal disorders Hepatitis A, B, or C Hypertension (high blood pressure) Liver problems Pneumonia Shortness of breath Dizziness Epilepsy Seizures Fainting High or low blood sugar Hypotension (low blood pressure) Heart attack/stroke Heart surgery Pacemaker Artificial valves Congenital heart defect Artificial bones/joints HIV/AIDS Fever blisters Sinus problems Severe/frequent headaches Radiation treatments Psychiatric problems Tuberculosis Abnormal bleeding Ulcers/colitis Difficulty breathing Emphysema Glaucoma Angina Chest pain Circulatory problems Cold sores Cortisone medicine Herpes Excessive thirst Heart disease Hives/skin rash Irregular heartbeat Lung disease Osteoporosis Sexually transmitted disease Sickle cell anemia Yellow jaundice Cough-persistent or bloody Latex sensitivity Smoker Swelling of feet/ankles Swollen neck glands Tonsillitis Tumor or growth on head/neck Anaphylaxis Alzheimer's diseaseHave you ever had an adverse reaction or allergies to any medication or substance?Check all that apply.* None Acrylic Aspirin Codeine Barbiturates (sleeping pills) Dental anesthetics Erythromycin Iodine Latex rubber Metals Nitrous oxide Novocaine Penicillin/antibiotics Sedatives Sulfa drugs Tetracycline Valium XylocaineAre you being/have you ever been treated for cancer of any kind? If yes, please explain*Are you currently taking or have you ever taken any bisphosphonate drugs? These include: alendronate (Fosamax), clodronate (Ostac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), tiludronate (Skelid), zoledronic acid (Zometa).*YesNoDo you use alcohol, cocaine, or other drugs?*YesNoHave you been treated in a hospital in the last five years?*YesNoIf female, please mark if you are: Pregnant Trying to get pregnant Nursing On birth control None of the abovePlease list all current prescriptions:*Please list any other serious medical conditions, impending operations, or other medical/dental information that may possibly affect your dental treatment:*Do you wish to talk to the dentist privately about any problems/concerns?* Yes NoAll of the above information is correct to the best of my knowledge. 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. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.Signature (Type your name to sign electronically, or print and sign)*Date (mm/dd/yyyy)* Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.