Patient Information
Name*
First Middle Last
Sex*
Date of Birth*
MM slash DD slash YYYY
Marital Status*
Social Security #*
Driver's Licence State*
Driver's Licence #*
Home Phone*
Work Phone*
Cell Phone*
E-mail Address*
Home Address
Street Address City State / Province / Region ZIP / Postal Code
Employer's Name
Best places and times to contact you
Send appointment reminders via*
Please tell us where you heard about us (check all that apply):*
Was our website a factor in your decision to visit our practice? Yes No*
- Yes
- No
Emergency Contact
First Name*
Last Name*
Relationship to Patient*
Home Phone*
Work Phone*
Cell Phone*

Person Responsible for Account
Name*
First Middle Last
Relationship to Patient*
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Driver's Licence State*
Driver's Licence #*
Holder of Dental Insurance for Patient*
Home Phone*
Work Phone*
Cell Phone*
E-mail Address*
Billing Address
Street Address City State / Province / Region ZIP / Postal Code
Employer's Name
Primary Insurance
Insurance Holder's Name*
Date of Birth*
MM slash DD slash YYYY
Relationship to Patient*
Employer
Member ID*
Group ID*
Insurance Company Name*
Insurance Company Phone*
Secondary Insurance
Insurance Holder's Name
Date of Birth
MM slash DD slash YYYY
Relationship to Patient
Employer
Member ID
Group ID
Insurance Company Name
Insurance Company Phone
Authorization
All 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 Sean T. Ky, DDS Inc. to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to Sean T. Ky, DDS Inc.. I permit a copy of this authorization to be used in place of the original. I give Sean T. Ky, DDS Inc., 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 slash DD slash YYYY

Consent for Treatment
Patient Name*
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.
Signature (Type your name to sign electronically, or print and sign)*
Date*
MM slash DD slash YYYY
Payment Policies
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.
For Patients with Dental Insurance
We 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 Checks
Personal checks that are returned due to "insufficient funds" are subject to a $25.00 service fee.
Service Charge
Payment 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.
Minors
Adult 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 made.
Authorization
Patient Name*
I hereby authorize payment directly to Sean T. Ky, DDS Inc. 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 Sean T. Ky, DDS Inc. 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.
Signature (Type your name to sign electronically, or print and sign)*
Date*
MM slash DD slash YYYY

Last Dental Visit
Last Dental Visit
MM slash DD slash YYYY
What were you treated for?
Treatment complete?
- Yes
- No
Last X-Rays
MM slash DD slash YYYY
Last Full-Mouth X-Rays
MM slash DD slash YYYY
Last Cleaning
MM slash DD slash YYYY
Today's Visit
Do you have any dental problems, pain, or discomfort at this time?*
Please describe*
What is the main reason for your visit today?*
Teeth
Check all that apply
Gums
Check all that apply
Facial/Jaw Pain
Check all that apply
Other Concerns
Check all that apply
Does food tend to get caught between your teeth?*
Where?*
Do you hold foreign objects (pencils, pipe, pins, nails, fingernails, etc.) with your teeth?*
What?*
Have you ever had
Is there anything you don't like about your teeth/smile?
Is there anything you'd like to change about your teeth/smile?

Smoking/dipping
Biting cheeks or lip
Popping/clicking
TMJ
Tooth-colored fillings
Wisdom teeth
Nail-biting
Sleep apnea
Limited orthodontics
Orthodontic treatment
Burning tongue
Tooth replacement
Fractured tooth syndrome
CPAP
Implants - Tooth
Jaw locks open/closed
Stain
Chew on one side
Snoring
Teeth straightening
Retainer
Dry mouth
Wisdom teeth extraction
Cosmetics
Smile makeover
Dental phobias

Abnormal bleeding
Alzheimer's disease
Anaphylaxis
Anemia
Angina
Arthritis
Artificial bones/joints
Artificial hip/joints
Artificial valves
Asthma
Blood disease
Blood transfusions
Bruise easily
Cancer
Cancer/chemotherapy
Chest pain
Cold sores
Congenital heart defect
Congenital heart lesion
Convulsions
Cortisone medicine
Cough-persistent or bloody
Diabetes
Difficulty breathing
Dizziness
Easily winded
Emphysema
Epilepsy
Excessive thirst
Fainting
ever blisters
Frequent diarrhea
Genital herpes
Glaucoma
Gout
Hay fever
Heart attack/stroke
Heart disease
Heart murmur/trouble
Heart surgery
Hemophilia
Hepatitis A, B, or C
Herpes
History of substance abuse/drug addiction
HIV/AIDS
Hives/skin rash
Hospitalized for any reason
Hypertension (high blood pressure)
Hypoglycemia
Hypotension (low blood pressure)
Irregular heartbeat
Kidney problems
Latex sensitivity
Leukemia
Liver problems
Lung disease
Mitral valve prolapse
Nervous disorder
Osteoporosis
Pacemaker
Pain in jaw joints
Parathyroid disease
Psychiatric problems
Radiation treatments
Recent weight loss
Renal dialysis
Rheumatic fever
Rheumatism
Scarlet fever
Seizures
Severe/frequent headaches
Sexually transmitted disease
Shingles
Sickle cell anemia
Sinus problems
Sinus trouble
Smoker
Spina bifida
Swelling of feet/ankles
Swollen neck glands
Swollen, still painful joints
Thyroid disease
TMD/TMJ (jaw pain)
Tonsillitis
Tuberculosis
Tumor or growth on head/neck
Ulcers/colitis
Venereal disease
X-ray or cobalt treatment
Yellow jaundice

Step 1 of 5

Patient Information

Emergency Contact

Person Responsible for Account

Primary Insurance

Secondary Insurance

Authorization

Consent for Treatment

Payment Policies

For Patients with Dental Insurance

Returned Checks

Service Charge

Minors

Authorization

Last Dental Visit

Today's Visit

Teeth

Gums

Facial/Jaw Pain

Other Concerns