Patient Forms

To provide the best possible dental and oral healthcare it necessary to have

a comprehensive understanding of the patient’s overall health.

The past and present health conditions of a patient and the medications they are taking are

important factors in determining the proper diagnosis and treatment for many oral conditions.

To accurately obtain this information and help expedite the process we encourage patients to

download and complete the appropriate forms and return them to our office in advance of their appointment.

Download the Appropriate Form(s) to Your Computer, Tablet, or Smart Phone.

Then Complete and Save the Form(s) for Your Records.

After Completing the Appropriate Forms and Saving the File to Your Device

the Saved Form(s) Can Then Be Securely and Safely Submitted to Our Office

Through the Submit Forms Page of This Website.

After downloading the appropriate forms you will need a PDF (Portable Document Format) reader to view, complete, submit, and/or print these forms. We recommend using the free Adobe Acrobat Reader DC to complete these tasks.

The forms below that can be downloaded, printed, and securely submitted

include the following:

Adult New Patient Information, Forms, and Procedures Packet

New patients need to download, review, and complete the necessary forms contained in this 8 page packet. This document combines all of the patient of the forms listed below in a single file to help simplify the extensive amount of paperwork that is required for today’s healthcare. For children that are 12years old or younger their parent or guardian need to download and complete the Child New Patient Health History & Account Information Forms instead of the adult forms.

To accurately obtain all of this necessary information and help expedite your appointment we encourage all new patients to download and complete all of these forms in advance of their appointment. This packet contains all the required forms for patients that are 13 years of years and older.

Click Here to Download the 9 Page Adult New Patient Health History & Account Information Packet

The following documents are contained in this single file:

Welcome Letter
Adult Health Information & History Form (2 pages)
Dental & Oral Health Information Form (1 page)
Oral Health Risk Factors Form (1 page)

Patient Account Information (1 Page)
Dental Insurance Information Form (1 Page)
Acknowledgement of Receipt of Privacy Practices (1page)
Request for Release of Dental Records from Previous Dentist (1page)

Child New Patie nt Ne w Patient Information, Forms, and Procedures Packet

Parents or guardians of children that are 12 years old or younger that are new patients need to download, review, and complete the necessary forms contained in this 6 page packet. This document combines all of the patient forms listed below in a single file to help simplify the extensive amount of paperwork that is required for a child’s oral healthcare.

To accurately obtain all of this necessary information and help expedite your child’s appointment we encourage you to complete all of these forms in advance of their appointment. This packet contains a significant amount of the information, the required forms, and the protocols that both the practice, parents, and patients need to follow today.

Click Here to Download the 7 Page Child New Patient Information, Forms, and Procedures Packet

The following documents are contained in this single file:

Welcome Letter
Child Health & Dental Information Form (2 pages)
Patient Account Information (1 page)

Dental Insurance Information Form (1 page)
Acknowledgement of Receipt of Privacy Practices (1page)
Request for Release of Dental Records from Previous Dentist (1 page)

At Home Health Assessment & Status Form

The U.S. Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA), and our ADA Standards Committees have established requirements for pre-screening patients before they arrive for any dental appointment. To help simplify this process we have developed an At Home Health Assessment & Status Form for our patients to use to evaluate their health status before their appointments.

Click Here to Download the 1 Page At Home Assessment & Status Form

Adult Health History & Dental Update Form

The status of our health changes over time, to provide the best possible dental and oral healthcare it is necessary to have a comprehensive understanding of the patient’s present overall health status. To accurately obtain this information and help expedite the process we encourage patients to regularly download this 4 page health history form. Additionally, we request patients bring a written list of the medications they are presently taking and the conditions they are being treated for with them to their appointment.

Click Here to Download the 3 Page Adult Health History Upadate Form

Child Health & Dental History Update Form

Request for Records from Previous Dentist Form

Update Dental Insurance Coverage Form

It is common that your dental insurance may change on a yearly basis. Most commonly this occurs on January 1st. However, some plans especially, dental insurance through schools may change on July 1st but it can occur at any time through the year. Additionally, if a change in employment for a patient or their spouse occurs there is normally a change in your insurance coverage. We must have all the correct information to enable us to properly submit your claims to help ensure you receive all the benefits that you are entitled to. Please download and use this form to update your dental insurance information for our office.

Click Here to Download the 1 page Dental Insurance Coverage Form

Update Patient and Family Account and/or Address Information Form

If you have had a change in your address, phone numbers, school, employer, email, or the person responsible for your account we need to be aware of these changes to properly communicate to you about your appointments, account, or other necessary communications. If you have dental insurance coverage, we must have all the correct information to for us to properly submit your claims to help ensure you receive all the benefits that you are entitled to.

Click Here to Download the 1 page Patient and Family Account Information Form

Information on the COVID-19 Pandemic on the Enhancements, & Policies for Patients

The COVID-19 (Corona) Virus pandemic has significantly changed the way we live our day to day life. Unfortunately, this also involves dentistry and oral health care. The U.S. Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA), and our ADA Standards Committees have established additional recommendations and requirements for the delivery of dental care. Our office follows these infection control recommendations and are working with these agencies to insure we are up-to-date on any new rulings or guidance that may be issued. We, at the Benjamin Dental Group, have always taken pride in our infection control procedures and providing the best possible care along with the development and utilization of state of the art technologies.

To assist our patients on understanding these changes and requirements we have created some guidance documents on the changes our office has made and the protocols and procedures our patients need to be aware of. Additionally, we have included some information from the CDC to assist in keeping everyone safe.

Click here to download this 4 page document.

Health Insurance Portability & Accountability Act (HIPAA) Privacy Statement

We respect your privacy and will never disclosure any of your personal health information without your permission. Unfortunately, you have the responsibility to list any additional person you would like us to share your health information with. This includes spouse, children, other family members, friends, or anyone else you feel, would be appropriate. This form is our Health Insurance Portability & Accountability Act (HIPAA) Privacy Statement that all patients need to read and understand.

Click Here to Download our 3 page Health Insurance Portability & Accountability Act (HIPAA) Privacy Statement