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785-274-9917

CALL US: 785.274.9917

2123 SW Fairlawn Plaza Dr

Topeka, KS 66614

Home
About
Services
Financial
Forms
Contact
Pay Your Bill

Request Appointment

Please fill out this form at least two (2) days before your scheduled dental appointment.

Once completed and submitted successfully, you will get the following message:

"Thank you for filling out our online form. We look forward to seeing you in our office soon. Have a great day. -Reed Dental Center"

All information provided is kept confidential.

New Patient Form

Appointment Date

How did you hear about our office?

Last Name

First Name

Preferred Name

Sex

Marital Status

Date of Birth

SSN

Address

City

State

Zip code

Email:

Phone:

School/Employer

Dental Insurance

Group Number

Member/Subscriber ID

Preferred Billing Method:

Preferred Pharmacy

Pharmacy Address

Pharmacy Phone Number

Primary Care Physician Name

Primary Care Physician Phone Number

When was your last dental visit?

Please tell us the reason for your visit:

Do you see a primary care physician regularly?

Yes

Is your overall health good/well maintained?

Yes

Are you currently on any prescription medications? (If yes, please list below.)

Yes

Have you been hospitalized or had a serious illness in the last year? (If yes, please answer below.)

Yes

Have you had excessive bleeding requiring special treatment in the past?

Yes

Do you have any illness or planned surgery preventing you from undergoing dental treatment?

Yes

Have you had problems with prior dental treatment?

Yes

Do you have any fear or anxiety when it comes to visiting the dentist?

Yes

Are you allergic to penicillin?

Yes

Are you allergic to latex?

Yes

Are you allergic to local anesthetics?

Yes

Do you have any other known allergies? (If yes, please list below.)

Yes

Are you currently pregnant or nursing, or plan to be?

Yes

Current, or previous, tobacco use?

Yes

Do you use any recreational drugs?

Yes

If needed, please explain any YES answers to the questions above:

Please list your medication(s):

Are you currently undergoing any medical treatment or have any planned medical treatment in the future?

Please check any conditions that apply:

Acid Reflux/Heartburn

ADHD

AIDS/HIV Positive

Alzheimer’s/Dementia

Anemia

Angina/Chest Pain

Anxiety

Arthritis

Artificial Joint

Asthma

Autism

Bipolar Disorder

Blood Disease/Condition

Breathing Problems

Cancer

Chemotherapy

Chest Pains

Chronic Neck Pain

Depression

Diabetes

Dizziness

Down Syndrome

Drug Addiction

Endocrine Problems

Epilepsy

Excessive Bleeding

Excessive Thirst

Fever Blisters/Cold Sores

Continued...

Gout

Glaucoma

Hay Fever

Headaches

Heart Attack

Heart Murmur

Heart Pacemaker

Heart Condition

Hepatitis

High Blood Pressure

High Cholesterol

Hypoglycemia

Kidney Problems

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Muscular Disorders

Organ Transplant

Osteoporosis

Prosthetic Heart Value

Psychiatric Care

Rheumatic Fever

Seizures

Sinus Problems

TMJ Problems

Tuberculosis

Other

PATIENT HIPAA CONSENT - I understand that I have certain rights to privacy regarding my protected health information. These rights are given under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This provides a safeguard to my privacy. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov We have adopted the following polices: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient health details will be stored digitally as an electronic health record (EHR). All computer monitors have HIPAA compliant views; these views will not contain any details which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administration areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by phone, text, email, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the front office administrator or the doctor. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Relationship to Patient

Date of Signature

NO-SHOW/CANCELLATION POLICY Description: No-Show - Patient who fails to arrive for a scheduled appointment. Same Day Cancellation - Patient who cancels an appointment less than 24 hours prior to their scheduled appointment. Policy: It is the policy of Reed Dental Center to monitor and manage appointment No-Shows/Late Cancellations. It is our goal to provide excellent care to each patient in a timely manner. Notification allows the practice to better utilize appointment times for all patients. Procedure: 1) In the event you miss an appointment without 24 hours notice or the appointment is a No-Show it will be counted as 1 documented No-Show/Cancellation. 2) On the second No-Show/Cancellation a $50.00 fee will be added to your account and will be collected prior to you being taken back at your next appointment. 3) If you have 3 documented No-Show/Cancellation appointments you will not be rescheduled. Your records will be sent to a provider of your choice. I have read and understand this policy:

Thank you for filling out our online form. We look forward to seeing you in our office soon.
Have a great day.

Reed Dental Center

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2123 SW Fairlawn Plaza Dr

Topeka, KS 66614

CALL US: 785.274.9917