New patient form bundle now available

Proper patient communication is key for a dental practice, and that begins when the patient first becomes a patient. Communicating all of the practice's policies and expectations is vital and that is why CDA has created a member-only New Patient Forms bundle. The bundle is a comprehensive resource pertaining to the gathering of information from the new patient. Dentists can implement the seven forms included in the bundle collectively or utilize them in an "a la carte" fashion if the practice has some, but not all, of the forms already in place.

The following are descriptions and instructions for each of the forms.

Confidential Health History Form

This form provides the practice a comprehensive report of a patient's health history, including essential dental health history information. The form can be completed at the start of a patient's appointment or prior to the appointment as long as the information is still current when the patient presents. Each health care provider should review the form prior to treating the patient. Be certain to allow time in your schedule for this review. Each new patient or a new patient's legal guardian should complete this form. Additionally, it should be reviewed at least every six months and completed every two years by active patients.

Certain areas of medical information bear confidentiality restrictions:

  • The release of mental health information requires the written authorization of both the patient and the physician or other professional person in charge of the patient.
  • The release of drug and alcohol abuse records may only be released without patient authorization pursuant to a court order (not a subpoena).
  • The release of HIV/AIDS status requires the written authorization of the patient that specifically authorizes disclosure of that status.
  • Pregnancy of a minor cannot be released to the parent or guardian without the minor's permission.

Dental Health History Form

This form is designed for the provider who wishes to collect more in-depth dental health history that is not covered on the Confidential Health History Form, as well as assess the patient's oral health and/or cosmetic concerns. This form helps assess the patient's interest in learning about specific oral health issues and aids the provider in offering educational resources on various dental health topics. This form can be completed prior to the patient's appointment or at the beginning of the initial appointment. This form should be reviewed by all providers working with the patient with the goal of addressing specific concerns expressed on the form with the patient. If this form is completed and received by the practice prior to the day of the patient's first appointment, relevant information completed on the form about the new patient should be shared in the practice's morning meeting.

New Patient Information Collection

This is a list of information a dental practice should include when creating a new patient form. Staff should check with patients annually to determine if any information on the form has changed, such as employer (which may indicate a change in dental benefit plan), address and contact numbers.

Patient Acknowledgments and Authorization

This document provides sample language for obtaining a patient's acknowledgment of responsibilities and receipt of information, obtaining a patient's affirmation that the provided information is correct and the patient agrees to treatment and payment terms, and for requesting a patient's authorization on communications. (Consent to treatment and to payment terms should be included in the treatment plan and financial agreement, respectively.) Ideally, these items should be added to the new patient form or at least completed at the same time the patient is filling in a new patient form.

Patient Personal Information Form

This form is designed for internal office use only. It should not be shared with the patient and is intended to provide the practice with a way to document personal information about the patient to help refresh staff members' minds prior to the patient visiting the practice. The information on this form can be collected over time as the team builds a relationship with the patient. This form also helps the practice document the patient's dental health history with the practice, in terms of the patient's willingness to accept treatment, anxiety toward dentistry and appointment history. This form should be reviewed by all staff who will be interacting with the patient prior to the patient's appointment. Any concerns regarding the patient's dental health (i.e., anxiety or resistance) should be communicated to the dental team in the morning meeting prior to the patient's appointment. For practices that use an electronic record system, the information can be entered in an area that can be viewed by all staff, but not seen by patients.

Coordination of Benefits Patient Questionnaire

Staff should use this questionnaire as a guide to collect information from the patient when coordination of benefits is necessary. Coordination of benefits is necessary when the patient has primary and secondary coverage, when the patient is a dependent covered by both parents, when the patient is a dependent of separated or divorced parents, or when the patient has coverage under a current and former employer. This questionnaire can be used at any point prior to the financial discussion with the patient. Often, a practice will verify dental benefits prior to the patient's first appointment. In this case, the questionnaire should be used with the patient over the phone to verify dental benefits prior to the first appointment.

Authorization for a Caretaker to Accompany a Minor Patient

This authorization form outlines consent by a legal guardian for a caretaker (nonlegal guardian) to accompany a minor to his/her dental appointment(s). This authorization does not permit a caretaker to consent to treatment of the minor child on behalf of the legal guardian. The provider should determine the type of appointments in which a nonlegal guardian is allowed to accompany a minor patient. Only legal guardians can consent to treatment and provide updates to the minor patient's health history.

Related Items

The New Patient Forms are provided as comprehensive resources pertaining to the gathering of information from the new patient. The forms can be implemented collectively or may be utilized in an “a la carte” fashion for the practice that may have some, but not all of the forms already in place.

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