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New Patient Paperwork

Complete your new patient paperwork online before your first visit to Bruce G. Jones Dentistry in Muskegon, MI.

Call (231) 780-5158

Request an Appointment

Please Complete the Paperwork Below

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Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent / Limited Authorization & Release

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process insurance claims.

Date*

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Name of Patient*

Legal Representative / Guardian

Relationship of Legal Representative / Guardian

Your comments regarding Acknowledgements or Consents

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA

First Name Only

Proper Surname

Other

If other, explain

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient’s records)

Name

Relationship

Name

Relationship

I Authorize Contact From This Office to CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION Via

Cell Phone

Home Phone

Work Phone

Text Message to my Cell Phone

Any

I Authorize INFORMATION ABOUT MY HEALTH Be Conveyed Via

Cell Phone

Home Phone

Work Phone

Text Message to my Cell Phone

Any

I Approve Being Contacted About SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on Behalf of This Healthcare Facility Via

Phone Message

Text Message

Any of the above

None (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Signature of Patient / Legal Guardian*

Your Name

Date*

Patient Information (Confidential)

Name*

Birthdate*

SS#*

Address*

City*

State*

Zip*

Home Phone

Cell Phone

Work Phone

Email*

Who may we thank for referring you?

Person to contact in an emergency*

Relationship*

Phone*

Check Appropriate Boxes*

Minor

College Student

Single

Married

Divorced

Widowed

Separated

Party Financially Responsible for This Account (If Different Than Patient)

Name

Birthdate

SS#

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Patient

Primary Dental Insurance (If Any)

Subscriber's Name

Relationship to Patient

Address (if different from patient)

City

State

Zip

DOB

SS#

Employer

Insurance Company

Group #

Contract #

Insurance Address

Insurance Phone

Secondary Dental Insurance (If Any)

Subscriber's Name

Relationship to Patient

Address (if different from patient)

City

State

Zip

DOB

SS#

Employer

Insurance Company

Group #

Contract #

Insurance Address

Insurance Phone

Financial Agreement

It is a pleasure to welcome you to our family dental practice.

Our goal is to provide you with quality care and attention during your appointment.

Appointments:

We ask that you make every effort to keep your appointments. This appointment time has been set aside for you; missing it will disrupt proper sequencing of your care and delay completion of your treatment. Our office utilizes a confirmation system that will contact you before your appointment by email, text or phone call. We ask that you please confirm your appointment via this system so we can adequately prepare for your appointment. If you miss this confirmation call, please call our office to confirm your appointment. We ask that you call at least 24 hours before your appointment if you need to cancel or reschedule. Failure to call 24 hours before will result in a broken appointment fee. We understand that family emergencies or sudden illnesses do arise, but please call the office to reschedule if this happens. When we have adequate notice of a cancellation, we are more likely to be able to offer that time to another patient. After three broken or missed appointments you will be dismissed from our practice.

Payment:

Payment is due at time of service. Our office accepts cash, personal checks, Master Card, Visa, Discover, American Express and Care Credit.

Insurance:

As a courtesy to you, we will help you process all of your dental insurance claims. Insurance coverage is subject to eliminations, exclusions, waiting periods, frequencies, age restrictions, deductibles, and maximums. It is your responsibility to be familiar with your dental plan. You may need to contact your insurance company to obtain your dental plan benefit information. We will provide you with an insurance estimate. This however is not a guarantee that your insurance will pay the exact amount estimated. Your benefits may differ due to a number of reasons as stated above. Your insurance company and your plan benefits ultimately determine the amount paid. Our office is committed to providing the best treatment for our patients. All charges you incur will be your responsibility, regardless of what your insurance covers. We must emphasize that as your dental care provider our relationship is with you, our patient, not your insurance company. We encourage you to be up to date with your coverage.

We ask that you please read and sign this letter as confirmation that you understand our office expectations. You will be given a copy to keep for future reference.

Thank you for coming to our office. We look forward to getting to know you and your family.

Patient Signature*

Your Name

Date*

Medical History

Patient Name*

Birthdate*

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?*

Yes

If yes, please provide name of physician.

Have you ever been hospitalized or had a major operation?*

Yes

If yes

Have you ever had a serious head or neck injury?*

Yes

If yes

Are you taking any medications, pills, or drugs?*

Yes

If yes

Are you taking, or have you taken, Xarelto or any other blood thinners?*

Yes

If yes

Are you taking, or have you taken, Phen-Fen or other weight loss pills?*

Yes

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*

Yes

If yes

Are you on a special diet?*

Yes

Do you use tobacco?*

Yes

Women: Are You…

Pregnant/Trying to get pregnant?

Yes

Nursing?

Yes

Taking Oral Contraceptives?

Yes

Are You Allergic to Any of the Following?

Aspirin*

Yes

Metal*

Yes

Penicillin*

Yes

Latex*

Yes

Codeine*

Yes

Sulfa Drugs*

Yes

Acrylic*

Yes

Local Anesthetics*

Yes

Other?*

Yes

If yes

Do you use controlled substances?*

Yes

If yes

Do You Have, or Have You Had, Any of the Following?

AIDS/HIV Positive*

Yes

Alzheimer's Disease*

Yes

Anaphylaxis*

Yes

Anemia*

Yes

Angina*

Yes

Arthritis Gout*

Yes

Artificial Heart Valve*

Yes

Artificial Joint*

Yes

Asthma*

Yes

Blood Disease*

Yes

Blood Transfusion*

Yes

Breathing Problems*

Yes

Bruise Easily*

Yes

Cancer*

Yes

Chemotherapy*

Yes

Chest Pains*

Yes

Cold Sores / Fever Blisters*

Yes

Congenital Heart Disorder*

Yes

Convulsions*

Yes

Cortisone Medicine*

Yes

Diabetes*

Yes

Drug Addiction*

Yes

Easily Winded*

Yes

Emphysema*

Yes

Epilepsy or Seizures*

Yes

Excessive Bleeding*

Yes

Excessive Thirst*

Yes

Fainting Spells Dizziness*

Yes

Frequent Cough*

Yes

Frequent Diarrhea*

Yes

Frequent Headaches*

Yes

Genital Herpes*

Yes

Glaucoma*

Yes

Hay Fever*

Yes

Heart Attack Failure*

Yes

Heart Murmur*

Yes

Heart Pacemaker*

Yes

Heart Trouble/Disease*

Yes

Hemophilia*

Yes

Hepatitis A*

Yes

Hepatitis B or C*

Yes

Herpes*

Yes

High Blood Pressure*

Yes

High Cholesterol*

Yes

Hives or Rash*

Yes

Hypoglycemia*

Yes

Irregular Heartbeat*

Yes

Kidney Problems*

Yes

Leukemia*

Yes

Liver Disease*

Yes

Low Blood Pressure*

Yes

Lung Disease*

Yes

Mitral Valve Prolapse*

Yes

Osteoporosis*

Yes

Pain in Jaw Joints*

Yes

Parathyroid Disease*

Yes

Psychiatric Care*

Yes

Radiation Treatments*

Yes

Recent Weight Loss*

Yes

Renal Dialysis*

Yes

Rheumatic Fever*

Yes

Rheumatism*

Yes

Scarlet Fever*

Yes

Shingles*

Yes

Sickle Cell Disease*

Yes

Sinus Trouble*

Yes

Spina Bifida*

Yes

Stomach Intestinal Disease*

Yes

Stroke*

Yes

Swelling of Limbs*

Yes

Thyroid Disease*

Yes

Tonsillitis*

Yes

Tuberculosis*

Yes

Tumors or Growths*

Yes

Ulcers*

Yes

Venereal Disease*

Yes

Yellow Jaundice*

Yes

Have you ever had any serious illness not listed?*

Yes

If yes

Comments

To the best of my knowledge, the questions on this form have been accurately answered. 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.

Signature of Patient, Parent or Guardian:*

Your Name

Date*

Dental History

How would you rate the condition of your mouth?*

Excellent

Good

Fair

Poor

Previous dentist

How long have you been a patient?

Date of most recent dental exam

Date of most recent x-rays

I routinely see my dentist every:*

3mo

4mo

6mo

12mo

Not Routinely

What is your immediate concern?

Personal History

Are you fearful of dental treatment?*

Yes

If yes, how fearful on a scale of 1 (least) to 10 (most)

Have you had an unfavorable dental experience?*

Yes

Have you ever had complications from past dental treatment?*

Yes

Have you ever had trouble getting numb or had any reactions to local anesthetic?*

Yes

Did you ever have braces, orthodontic treatment or had your bite adjusted?*

Yes

Have you had any teeth removed?*

Yes

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change?*

Yes

Have you ever whitened (bleached) your teeth?*

Yes

Have you felt uncomfortable or self-conscious about the appearance of your teeth?*

Yes

Have you been disappointed with the appearance of previous dental work?*

Yes

Bite and Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping)*

Yes

Do you/would you have any problems with chewing gum?*

Yes

Do you/would you have any problems chewing bagels, baguettes or other hard food?*

Yes

Have your teeth changed in the last 5 years, become shorter, thinner or worn?*

Yes

Are your teeth crowding or developing spaces?*

Yes

Do you have more than one bite and squeeze to make your teeth fit together?*

Yes

Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits?*

Yes

Do you clench your teeth in the daytime or make them sore?*

Yes

Do you have any problems with sleep or wake up with an awareness of your teeth?*

Yes

Do you wear or have you ever worn a bite appliance?*

Yes

Tooth Structure

Have you had any cavities within the past 3 years?*

Yes

Does the amount of saliva in your mouth seem low or do you have difficulty swallowing food?*

Yes

Do you feel or notice any holes (pitting or craters) on the biting surface of your teeth?*

Yes

Are any teeth sensitive to hot, cold, sweets or do you avoid brushing any part of your mouth?*

Yes

Do you have grooves or notches on your teeth near the gum line?*

Yes

Have you ever broken teeth, chipped teeth, had a toothache or cracked filling?*

Yes

Do you get food caught between any teeth?*

Yes

Gum and Bone

Do your gums bleed when brushing or flossing?*

Yes

Have you ever been treated for gum disease or been told you have lost bone around your teeth?*

Yes

Have you ever noticed an unpleasant taste or odor in your mouth?*

Yes

Is there anyone with a history of periodontal disease in your family?*

Yes

Have you ever experienced gum recession?*

Yes

Have you ever had any teeth become loose on their own?*

Yes

Have you experienced a burning sensation in your mouth?*

Yes

Signature of Patient / Legal Guardian:*

Your Name

Date*

Visit Our Muskegon Office

30 W Norton Ave, Muskegon, MI 49444
(231) 780-5158
[email protected]
Mon and Tue 8 AM to 5 PM, Wed 8 AM to 7 PM, Fri 8 AM to 2 PM, Thu closed

Request an Appointment

Related Services

Preventive Dentistry
Cosmetic Dentistry
Orthodontics
Restorative Dentistry
Oral Surgery
Additional Dental Services

We accept Delta Dental

Delta Dental, MetLife and most major PPO plans. We file your claim for you. Check your coverage.

Why Families Choose Bruce G. Jones Dentistry

30+ Years in Muskegon

Dr. Jones has cared for Muskegon families for more than three decades.

University of Michigan DDS

Doctor of Dental Surgery and a member of the Michigan and American Dental Associations.

Comfort-First Care

Gentle, patient-focused visits with laughing gas available for anxious patients.

Accepting New Patients

Families of all ages are welcome. Delta Dental and other plans accepted.

Ready to schedule your visit?

Call our Muskegon office or request an appointment online. New patients are always welcome.

Call (231) 780-5158

Request an Appointment

Menu

New Patient Paperwork

Please Complete the Paperwork Below

Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent / Limited Authorization & Release

Patient Information (Confidential)

Party Financially Responsible for This Account (If Different Than Patient)

Primary Dental Insurance (If Any)

Secondary Dental Insurance (If Any)

Financial Agreement

It is a pleasure to welcome you to our family dental practice.

Appointments:

Payment:

Insurance:

Medical History

Women: Are You…

Are You Allergic to Any of the Following?

Do You Have, or Have You Had, Any of the Following?

To the best of my knowledge, the questions on this form have been accurately answered. 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.

Dental History

Personal History

Smile Characteristics

Bite and Jaw Joint

Tooth Structure

Gum and Bone

Visit Our Muskegon Office

Related Services

We accept Delta Dental

Why Families Choose Bruce G. Jones Dentistry

30+ Years in Muskegon

University of Michigan DDS

Comfort-First Care

Accepting New Patients

Ready to schedule your visit?

Bruce G. Jones Dentistry

Hours

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