Martinez & Martinez Family Dental Care

Reason for Today’s Visit:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Home Address:
Zip Code:
Patient Social Security#:
Date of Birth:
Marital Status:
Full Time Student:
Name of School:
Whom may we contact in the case of an emergency?
Whom may we thank for referring you to us?
Who is responsible for this bill?
Date of last dental exam:
Name of previous dentist:
Did you sustain an injury at work?
Are you covered under an employer or union policy?
Are your injuries accident related?
Is your spouse or other family member employed?
Are you currently employed?
Do you have a secondary or medical insurance policy?

Dental Insurance Information

Name of Insured:
Relationship to Patient:
Policyholder Date of Birth:
Policyholder Social Security#:
Dental Insurance Carrier Name, Address, Phone#:
Identification card present upon encounter:
Eligibility date as indicated on card as:
Is the medical and dental carrier the same?
Insured’s Employer Name and Address:
Employer Phone#:
Insured’s Social Security #:

Other Dental Insurance Information

Name of Insured:
Relationship to Patient:
Policyholder Date of Birth:
Policyholder Social Security #:
Dental Insurance Carrier Name, Address, Phone #:
There are dental conditions that may have medical complications or etiology. To best assist our patients, we find having all information a valuable resource in determining the patient needs and insurance coverage.
Are you currently under the care of a physician?
Are you allergic to latex?
Have you previously been diagnosed with sleep apnea?
Have you been tested for sleep apnea?
Have you previously been diagnosed with TMJ or TMJD?
Have you received previous treatment TMJ or TMJD?
Have you ever had a reaction to Novacain or Anesthesia?
If so, please explain:

Martinez & Martinez Family Dental Care

Acknowledgment of Receipt of Notice of Privacy Practices

Purpose: This form is used to obtain acknowledgment of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgment.
,have received a copy of this office’s Notice of Privacy Practices.
Please Print Name
For Office Use Only
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because (circle one):
Individual refused to sign
Communication barriers prohibited obtaining the acknowledgment
An emergency situation prevented us from obtaining acknowledgment
Other (Please specify)
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication, or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).


Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.

  • Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment. We are not responsible for knowing your individual insurance plan. However, we do our best to obtain whatever information we can regarding your insurance, to better serve you. If you have questions that we cannot answer about your insurance we will refer you to call your insurance provider.
  • Our office places composite restorations only. Depending on your particular policy your insurance may not cover this benefit in full.
  • We require you to sign this form and/or any other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office.
  • We require you to pay the co-payment, and/or estimated outstanding balance which is the amount not covered by your insurance company, at the time we provide service to you. This is an estimated amount, we cannot guarantee an exact amount that will be paid by your insurance company.
  • Insurance payments ordinarily are received within 60 days from the time of billing. If your insurance company has not made payment to our office within 60 days, we will ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time.
  • Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time.
  • Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.
  • If you are a new patient we require you to bring in your most recent radiographs on the day of your examination. These are critical for diagnosis during an examination. Without radiographs your examination is not complete. If you do not have them with you at the time of the examination we will take them. Again, we are not responsible for what your insurance policy is regarding radiographs
  • Credit balances under $35.00 will not be returned without a written request after three years.
**Returned checks and balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month. Additionally, our office will charge you $50.00 for broken appointments and appointments without 48-hour advance notice.
Print Name
Signature of Patient/Responsible Party
Martinez & Martinez Family Dental Care
Birth Date
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operations?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet
Do you use tobacco?
Do you use controlled substances?
If yes, please explain:
If yes, please explain:
If yes, please explain:
If yes, please explain:
Women: Are you
Are you allergic to any of the following?
If yes, please explain:
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above?
If yes, Please Explain
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

Past or Present History of (circle all that apply):

Please circle any treatments you are interested in:

How often do you visit the dentist?
How often do you floss?
How often do you brush your teeth?
Are you in pain at this time?
For how long have you been in pain?
Is your pain due to an accidental injury or accident?

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or in the above information. This information will be kept confidential. I am responsible for updating this information if and when there are changes.

We welcome you to our office!! We look forward to getting and keeping your mouth healthy!!!
We are proud members of the AGD (Academy of General Dentistry), ADA (American Dental Association), IOA (International Association of Orthodontists) and AAFE (American Academy of Facial Esthetics).