Referral Information
How did you find us? Patient/Friend - Name: _______________________________________________
Insurance Provider List Internet Search Mailer Facebook Other ______________________ Patient Information
Patient Name: _________________________________________________ Date: _______________________ Parent/Guardian (if under 18): __________________________________ Sex: Male Female Status: Married Single Child Partner Other Social Security #:_______________________________ Date of Birth: __________________________________Phone (cell):___________________ (home): ___________________ (work): ___________________Ext:______ Preferred Telephone: Cell Home Work
Email:_____________________________________ May we email/text you appointment reminders? Yes No
Address: __________________________________________________________________________________________
__________________________________________________________________________________________ Employer: ___________________________________ Occupation: __________________________________Emergency Contact: __________________________________________________________________________ Spouse or Responsible Party Information
Policy Holder (complete this section) Other (complete this section) Patient Name: _________________________________________________ Date: _______________________ Social Security #:_______________________________ Date of Birth: __________________________________Phone (cell):___________________ (home): ___________________ (work): ___________________Ext:______Address: __________________________________________________________________________________________ __________________________________________________________________________________________ Insurance Information Self Pay / No Insurance
Policy Holder: _____________________________________________ Patient's Relation: _________________________ Birth Date: _______________________________ Social Security #: ____________________________________Insurance Company: ________________________ Employer: _____________________________________________ ID#: ______________________________________ Group #:_______________________________________________ Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
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.
____________________________________________ Date: _________________________ Relationship to Patient: _________________
Signature of patient, parent or guardian
1. Have you had any serious illness, operations or hospitalizations?
2. Are you under a physician's care at this time? Do you have or did you ever have any of the following?
Cardiovascular Health

Muscular-Skeletal/CNS/Mental Health
6. Coronary artery blockage or treatment (bypass, Gastro-Intestinal/Genito-Urinary Health
Respiratory Health
Medication Allergies and Other Allergies
Endocrine/Blood/Immune Health
21. Frequent thirst or frequent urination Females Only
60. Are you taking any prescription medications, over the counter medications or herbal medicines?
If so, please list them and the dose taken: 61. Do you or have you used bisphosphonate medication (Fosomax, Actonel, Boniva, Skelid, Didronel, Aredia, Zometa, Bonefos)? Social
62. Do you use tobacco?
65. Do you have any other medical conditions not already listed above? I hereby certify that I have read the foregoing and filled out this questionnaire completely. I have advised you of all medical problems of which I am aware. I further certify that I, the unsigned, consent to the performing of x-rays and examination.
Have there been any changes in your medical history, including any medications that you take, since you last completed this form? Dental Health Questionnaire
We believe that each patient deserves to know what their current level of dental health is, how they got there, and what treatment options are available to help them reach the level of health that they deserve. This begins with a careful diagnosis and personalized treatment plan. We will perform a comprehensive oral examination of your teeth, gums, jaw joints, bite and soft tissues. We will also take the appropriate x-rays, and when beneficial we may take additional diagnostic records such as photographs or casts of your teeth to further evaluate areas of concern. Once all your records have been completed they will be carefully evaluated to determine your current level of dental health. We will review our findings with you and discuss your treatment options. A personalized treatment plan will then be developed to help you achieve the goals we set together. Please help us better understand your dental health needs and goals by answering the following questions. (check the best answer): Have you had a full set of x-rays(other than routine cavity detecting x-rays)within the last 3 years? ( ) Yes ( ) No I have a ( ) low ( ) moderate ( ) high fear of going to the dentist.
I am ( ) very satisfied ( ) satisfied ( ) dissatisfied ( ) with the appearance of my teeth. I think my present state of dental health is ( ) excellent ( ) good ( ) fair ( ) poor ( ). I would say that my main concerns with my dental health are: _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ I am interested in a smile evaluation and personalized treatment plan to enhance my smile. ( ) Yes ( ) No Please check which statement below best represents the level of dental health you wish to achieve. (Some people begin at one level and progress to a higher level over time.) ( ) HEALTH LEVEL I – Emergency Care
I am only interested in emergency dental care for the relief of pain and/or cosmetic embarrassment. I am not very interested in thinking about the future of my teeth at this time. ( ) HEALTH LEVEL II – Maintenance Care
I am interested in maintenance care by taking an active part in the prevention of the disease process and the
repair of existing problems. However, I am not ready for a higher level of dental care due to limitations of time
and/or money. I understand that maintenance care may not be enough to help me achieve maximum protection
and longevity and that my dental health may not remain stable over time. ( ) HEALTH LEVEL III – Comprehensive Care
I am interested in comprehensive care to achieve and maintain a higher level of dental health. I am concerned about treating the causes of dental diseases, not simply the effects. I want all dental treatment provided to be the best available for maximum protection and longevity, so as to achieve long-term stable dental health. ( ) HEALTH LEVEL IV – Comprehensive & Cosmetic Care
I am interested in comprehensive and cosmetic care to achieve and maintain the highest level of dental health. I
am concerned about treating the causes of dental diseases, not simply the effects. I want all dental treatment
provided to be the best available in cosmetic dentistry for maximum protection, longevity, and esthetics, so as to
achieve long-term stable, yet esthetic dental health.
Sunrise Family Dentistry
Written Financial Policy
Thank you for choosing Sunrise Family Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering payment options. Payment Options:
- Cash, Visa, MasterCard, American Express, Discover Card or (Checks for existing patients) - Convenient Monthly Payment Options from CareCredit Patients that have no insurance:
Payment in full is due at the time service is rendered. We also offer an in-office Savings Plan to all of our patients.
Patients who have dental insurance coverage that pays the office:
All charges incurred are the responsibility of the patient or their guarantor, NOT the insurance company. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. Our office does not guarantee that your insurance company will assist with payment for any dental treatment. If your claim is not paid within 60 days, denied, or paid at a lesser amount, you will be responsible for paying the full amount at that time. Our practice will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. It is your responsibility to resolve any type of dispute over payments made or not made by your insurance company to our practice.
We always recommend treatment based on our patient’s dental needs, not based on insurance coverage, which is inadequate with some dental plans. We estimate what the insurance will pay based on information they have provided us, which is almost always generalized information. What the insurance actually pays will be determined when they process the claim. The estimated patient portion is due and payable at the start of treatment and if the insurance pays less than estimated, we will bill the remainder to the patient or guarantor with the expectation that the full balance will be paid in full within 20 days.
Please note:
Sunrise Family Dentistry requires payment at the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.
A fee of $25 is charged for patients who miss or cancel without a 24-hour notice.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Dental Materials Fact Sheet
What About the Safety of Filling
cury is emitted in minute amounts as vapor. Some con- Materials?
cerns have been raised regarding possible toxicity.
Scientific research continues on the safety of dental Patient health and the safety of dental treatments are the amalgam. According to the Centers for Disease Control primary goals of California’s dental professionals and the and Prevention, there is scant evidence that the health of Dental Board of California. The purpose of this fact sheet the vast majority of people with amalgam is compro- is to provide you with information concerning the risks and benefits of all the dental materials used in the The Food and Drug Administration (FDA) and other public health organizations have investigated the safety of amal- The Dental Board of California is required by law* to gam used in dental fillings. The conclusion: no valid scien- make this dental materials fact sheet available to every tific evidence has shown that amalgams cause harm to licensed dentist in the state of California. Your dentist, in patients with dental restorations, except in rare cases of turn, must provide this fact sheet to every new patient allergy. The World Health Organization reached a similar and all patients of record only once before beginning any conclusion stating, “Amalgam restorations are safe and As the patient or parent/guardian, you are strongly A diversity of opinions exists regarding the safety of den- encouraged to discuss with your dentist the facts pre- tal amalgams. Questions have been raised about its sented concerning the filling materials being considered safety in pregnant women, children, and diabetics.
However, scientific evi-dence and research literature inpeer-reviewed scientific journals suggest that otherwise Allergic Reactions to Dental
healthy women, children, and diabetics are not at anincreased risk from dental amalgams in their mouths. The Materials
FDA places no restrictions on the use of dental amalgam.
Components in dental fillings may have side effects or Composite Resin
cause allergic reactions, just like other materials we maycome in contact with in our daily lives. The risks of such Some Composite Resins include Crystalline Silica, which reactions are very low for all types of filling materials.
is on the State of California’s Proposition 65 list of chem- Such reactions can be caused by specific components of icals known to the state to cause cancer.
the filling materials such as mercury, nickel, chromium,and/or beryllium alloys. Usually, an allergy will reveal It is always a good idea to discuss any dental treatment itself as a skin rash and is easily reversed when the indi- vidual is not in contact with the material.
Dental Amalgam Fillings
There are no documented cases of allergic reactions tocomposite resin, glass ionomer, resin ionomer, or porce- Dental amalgam is a self-hardening mixture of silver-tin- lain. However, there have been rare allergic responses copper alloy powder and liquid mercury and is some- reported with dental amalgam, porcelain fused to metal, times referred to as silver fillings because of its color. It is gold alloys, and nickel or cobalt-chrome alloys.
often used as a filling material and replacement for bro-ken teeth.
If you suffer from allergies, discuss these potential prob-lems with your dentist before a filling material is chosen.
Toxicity of Dental Materials
Wears well; holds up well to the forces of biting Dental Amalgam
Mercury in its elemental form is on the State of Self-sealing; minimal to no shrinkage and California’s Proposition 65 list of chemicals known to the state to cause reproductive toxicity. Mercury may harm Resistance to further decay is high, but can be the developing brain of a child or fetus.
Frequency of repair and replacement is low Dental amalgam is created by mixing elemental mercury(43-54%) and an alloy powder (46-57%) composed main- Disadvantages
ly of silver, tin, and copper. This has caused discussionabout the risks of mercury in dental amalgam. Such mer- Refer to “What About the Safety of FillingMaterials” * Business and Professions Code 1648.10-1648.20 Glass Ionomer Cement
May darken as it corrodes; may stain teeth overtime Glass ionomer cement is a self-hardening mixture of glass and organic acid. It is tooth-colored and varies in In larger amalgam fillings, the remaining tooth translucency. Glass ionomer is usually used for small fill- ings, cementing metal and porcelain/metal crowns, lin- Because metal can conduct hot and cold tem- peratures, there may be a temporary sensitivity Advantages
Contact with other metals may cause occasion- May provide some help against decay becauseit releases fluoride The durability of any dental restoration is influenced not Minimal amount of tooth needs to be removed only by the material it is made from but also by the den- and it bonds well to both the enamel and the tist’s technique when placing the restoration. Other fac- tors include the supporting materials used in the proce- Material has low incidence of producing tooth dure and the patient’s cooperation during the procedure.
The length of time a restoration will last is dependent upon your dental hygiene, home care, and diet and Disadvantages
Composite Resin Fillings
Cost is very similar to compos-ite resin (whichcosts more than amalgam) Composite fillings are a mixture of powdered glass and Limited use because it is not recommended for plastic resin, sometimes referred to as white, plastic, or tooth-colored fillings. It is used for fillings, inlays, As it ages, this material may become rough and veneers, partial and complete crowns, or to repair por- could increase the accumulation of plaque and Does not wear well; tends to crack over time Advantages
Resin-Ionomer Cement
Resin ionomer cement is a mixture of glass and resin polymer and organic acid that hardens with exposure to a blue light used in the dental office. It is tooth colored but Small risk of leakage if bonded only to enamel more translucent than glass ionomer cement. It is most often used for small fillings, cementing metal and porce- Generally holds up well to the forces of biting Resistance to further decay is moderate and Advantages
Frequency of repair or replace-ment is low to May provide some help against decay because Disadvantages
Minimal amount of tooth needs to be removedand it bonds well to both the enamel and the Refer to “What About the Safety of Filling Moderate occurrence of tooth sensitivity; sensi- tive to dentist’s method of application May hold up better than glass ionomer but not Material shrinks when hardened and could lead to further decay and/or temperature sensitivity Material has low incidence of producing tooth May leak over time when bonded beneath thelayer of enamel Disadvantages
High cost; requires at least two office visits and Cost is very similar to composite resin (which Limited use because it is not recommended torestore the biting surfaces of adults Porcelain Fused to Metal
This type of porcelain is a glass-like material that is Porcelain (Ceramic)
“enameled” on top of metal shells. It is tooth-colored andis used for crowns and fixed bridges Porcelain is a glass-like material formed into fillings orcrowns using models of the prepared teeth. The material Advantages
is tooth-colored and is used in inlays, veneers, crownsand fixed bridges.
Good resistance to further decay if the restora-tion fits well Advantages
The material does not cause tooth sensitivity Very little tooth needs to be removed for use as Resists leakage because it can be shaped for a a veneer; more tooth needs to be removed for acrown because its strength is related to its bulk Good resistance to further decay if the restora- Disadvantages
More tooth must be removed (than for porce- Is resistant to surface wear but can cause some Higher cost because it requires at least two Resists leakage because it can be shaped for a The material does not cause tooth sensitivity Gold Alloy
Gold alloy is a gold-colored mixture of gold, copper, andother metals and is used mainly for crowns and fixed Material is brittle and can break under biting bridges and some partial denture frameworks Advantages
Higher cost because it requires at least two Good resistance to further decay if the restora-tion fits well Nickel or Cobalt-Chrome Alloys
Excellent durability; does not fracture understress Nickel or cobalt-chrome alloys are mixtures of nickel and chromium. They are a dark silver metal color and are Minimal amount of tooth needs to be removed used for crowns and fixed bridges and most partial den- Wears well; does not cause excessive wear to Resists leakage because it can be shaped for a Advantages
Good resistance to further decay if the restora-tion fits well Disadvantages
Excellent durability; does not fracture under Conducts heat and cold; may irritate sensitive Minimal amount of tooth needs to be removed High cost; requires at least two office visits and Resists leakage because it can be shaped for a DENTAL BOARD OF CALIFORNIA
1432 Howe Avenue • Sacramento, California 95825 Is not tooth colored; alloy is a dark silver metalcolor CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS Conducts heat and cold; may irritate sensitive Sunrise Family Dentistry
Patient Acknowledgement of Receipt of Dental Materials Facts Sheet and Notice of Privacy Practices As of January 1, 2002, the Dental Board of California now requires that we distribute toour patients a copy of the Dental Materials Facts Sheet. In addition, the Health Insurance Portability and Accountability Act (HIPAA) requires, effective April 14, 2003, that patient be given a copy of our Notice of Privacy Practice. Please print and sign your name below.
I, ______________________________, acknowledge I have received from this office: 1. A copy of the Dental Materials Fact Sheet2. The Notice of Privacy Practice Patient Signature or Personal Representative If signed by a personal Representative of the Patient, describe the representative’s authority to act for the patient ________________________________________________________ _______________________________________________________________________ We attempted to obtain written acknowledgment of receipt of our Notice of PrivacyPractices, but acknowledgement could not be obtained because: Individual refused to signCommunications barriers prohibited obtaining acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (please specify) ____________________________________________________________________
  • WD Form41-1008-HealthHistory_Rev.16
  • WD Form41-1008-HealthHistory_Rev.16
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