Sahara Dental Center

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About us/
Dental Emergency/
Reviews and Testimonials/
Special Offers/
Smile Make Over/
Easy Finance/
Services/
Insurances/
Teeth Cosmetic/
Implant/
Invisalign/
Careers/
Blog/
Payment/
Contact us/

YOUR COMFORT IS OUR PASSION

New Patient e-Form

About us/
Dental Emergency/
Reviews and Testimonials/
Special Offers/
Smile Make Over/
Easy Finance/
Services/
Insurances/
Teeth Cosmetic/
Implant/
Invisalign/
Careers/
Blog/
Payment/
Contact us/

New Patient Form

Name: *

First Name

Last Name

Date of Birth: *

YYYY

SSN:

Cell Phone: *

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Email Address: *

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact: *

First Name

Last Name

Emergency Cell phone: *

(###)

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Relation to Patient: *

Reason for Today’s Visit: *

Last Visit to The Dentist:

YYYY

Name of Office/Dentist you visited:

Any Negative Dental Experience? (Optional)

Do you have Dental Insurance? *

Dental Insurance Information:

Insurance Name

Subscriber

ID Number

Subscriber DOB (if other selected)

Relationship to Patient (if other selected)

Secondary Insurance (if any):

Secondary Insurance Name

Secondary Insurance subscriber

Secondary Insurance ID Number

Secondary Insurance Subscriber DOB

For the following questions, please select yes or no, whichever applies.

Are you in good health? *

Are you currently under the care of a physician? *

Physician’s Name (if any)

Have you had any serious illness, operation or been hospitalized? *

Please Explain (if yes)

Do you have or have you had any of the following disease or problems?

Rheumatic fever or rheumatic heart disease *

Congenital health lesions? Heart murmur? *

Artificial bones / Joints *

Heart attack/ Stroke / Pacemaker *

Kidney problems *

Diabetes *

Tuberculosis *

Thyroid problems *

Epilepsy / Seizures/ Fainting spells *

Ulcers / Colitis *

Asthma / Arthritis *

High / Low blood pressure *

Experience pain / Discomfort in your joints *

Psychiatric problems *

Hepatitis *

HIV Positive *

Are you presently taking any medications? If so, please list

Are you allergic or have reacted adversely to:

Penicillin, Erythromycin, Amoxicillin or other antibiotic *

Sulfa drugs *

Codeine or other narcotics *

Aspirin *

Local anesthetics *

Other

Please explain

For Women

Are You Taking Birth Control Pills?

Are You Pregnant?

If Yes, Month Number

Are You Nursing?

To the best of my knowledge, I agree that the information given today is correct and it is my responsibility to inform this office of any changes in my medical stats. I authorize the dental staff to perform the necessary dental services that I may need. I understand that payment is due in full at time of treatment unless prior arrangements have been approved. *

initials

Name of patient / legal guardian *

First Name

Last Name

Today's Date *

YYYY

Financial Policy (Your Initials if Agree)

Thank you for choosing American Dental for your treatment. Our goal is to provide you with the best possible dental care and help you to maintain your teeth for a lifetime. Out office manager will be available to discuss your insurance, financial or care credit needs, if necessary. We accept personal checks, as well as MasterCard and Visa for your convenience. *

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As a matter of courtesy to our patients, we will bill your insurance carrier. We will submit the original insurance claim and follow-up claim if necessary; however, you are responsible for the entire bill. If your insurance carrier does not remit payment within 60 days from the time the claim has been submitted, the balance will due in full from and you should contact your insurance carrier to find out why payment has been has been delayed. If there are any payments made our your insurance carrier in excess of the estimated balance, we will refund the credit amount owed to you, unless you ask us to retain the balance for your immediate dental treatment. *

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A monthly billing fee of 1.5% interest will be charged to your account for any balance due over 60 days. We require a 48 hour notice prior to your appointment if you are unable to keep it. A fee of $50.00 may be charged for broken appointments. *

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The fee listed is applicable if treatment is commenced within 60 days. *

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I completely understand the financial policy as stated above and as such. I agree that the total cost of the treatment is my responsibility. *

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How did you hear about our office? Select all that apply. *

Google

Facebook

Twitter

Instagram

Snapchat

Insurance company

Groupon

Event

Door sign

Referred by a friend/family member

Referred by a doctor/dentist

Other

Thank you for applying!

About us/
Dental Emergency/
Reviews and Testimonials/
Special Offers/
Smile Make Over/
Easy Finance/
Services/
Insurances/
Teeth Cosmetic/
Implant/
Invisalign/
Careers/
Blog/
Payment/
Contact us/

Sahara Dental Center

364 Harvard Street, Suite 1C, Brookline, MA 02446

For any dental emergency please call/text (857) 218 8222

To book an appointment, please call (617) 232 6188

E: info@saharadentalcenter.com