Patient Information

Patient Information

Please fill out the information below, print, and bring to your first appointment. Afterward, please visit all the below links, print the documents, fill them out, and bring them with you also.

DouglasDental_Privacyform

DouglasDental_OralIDconsentform

DouglasDental_OfficePoliciesForm

Dental Insurance

Assignment and Release

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

and assign directly to Dr. Boutwell 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(ies) 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

______________________________________

Please print name of Patient, Parent, Guardian or Personal Representative

______________________________________

If Parent, Guardian or Personal Representative, please indicate relationship to patient

______________________________________

Phone Numbers

In Case of Emergency, Contact (Specify someone who does not live in your household)

Dental History

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Health History

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine).Pondimin (fenfluramine) and Redux (dexfenfluramine):

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Women

Medications

Allergies   Please indicate yes or no to any allergies you may have

Please fill out the above information, print, and bring to your first appointment. Once you complete this form, please open and print each of the following forms, fill them out (they are all short!), and bring them with you.

DouglasDental_Privacyform

DouglasDental_OralIDconsentform

DouglasDental_OfficePoliciesForm