New Patient Information

Welcome to our practice.
Please take your time to fill out this form completely. The more we
learn about you, the better personal care we are able to provide. We look
for-ward to working with you to maintain a healthy, happy smile.
  • Today's date
  • First name
  • Middle name
  • Last name
  • I prefer to be called (nickname, etc.)
  • Male Female
  • Address
  • City
  • State
  • Zip:
  • Date of birth
  • Age
  • Social Security No.
  • Home phone
  • Work phone
  • Cell phone
  • Primary contact number (please check one)
  • Home Work Cell
  • Best time to call
  • Driver's license no.
  • E-mail
  • Do you have a preference for appointment times?
  • Yes No
  • When?
  • Employer
  • Occupation
  • Spouse's name
  • Spouse's employer
  • Whom may we thank for referring you?
  • Reason for today's visit
  • Are you currently in pain?
  • Yes No
  • If so, please describe:
  • Do you have any dental problems now?
  • Yes No
  • If so, please describe:
  • Have you ever had trouble with a previous dental treatment?
  • Yes No
  • If so, please describe:
  • Level of anxiety about seeing the dentist:
  • (least)
  • 1 2 3 4 5
  • (most)
  • Date of last dental exam
  • Date of last cleaning
  • Date of last full mouth X-rays
  • Procedure(s) done at last dentist visit
  • Previous dentist's name
  • Are you changing dentists?
  • Yes No
  • Why?
  • How often do you have dental examinations?
  • How often do you brush your teeth?
  • How often do you floss?
  • What type of bristles do you use?
  • Hard Medium Soft
  • What other dental aids do you use? (Mouth rinse, electric toothbrush, toothpick, etc.)
      • Do you require antibiotics before dental treatment?
      • Yes No
      • Do your gums ever bleed?
      • Yes No
      • Have you noticed any mouth odors or bad tastes?
      • Yes No
      • Do you bite your lips or cheeks frequently?
      • Yes No
      • Do you have frequent headaches?
      • Yes No
      • Do you clench or grind your teeth?
      • Yes No
      • Are your teeth sensitive to heat/cold?
      • Yes No
      • Do you still have your wisdom teeth?
      • Yes No
  • Is there anything else that you want our office to know about you that will help us to serve you better?
  •  
  • We Appreciate Your Referrals.


New Patient Information
  •  
    • Have you ever had:
      • Periodontal disease/gum treatment
      • Yes No
      • Orthodontics treatment
      • Yes No
      • Oral surgery
      • Yes No
      • A bite plate or mouth guard
      • Yes No

      • Discomfort in your jaw joint (TMJ/TMD)
      • Yes No
      • Your teeth ground or bite adjusted
      • Yes No
      • Serious injury to the mouth or head
      • Yes No
  • If yes to any of the previous questions, please describe
  • Is there anything else about your past dental treatment(s) that you would like us to know?
  •  
Medical History
  • Although dental personnel primarily treat 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 No
  • If yes
  • Have you ever been hospitalized or had a major operation?
  • Yes No
  • If yes
  • Have you ever had a serious head or neck injury?
  • Yes No
  • If yes
  • Are you taking any medication, pills, or drugs?
  • Yes No
  • If yes
  • Do you take, or have you taken, Phen-Fex or Redux?
  • Yes No
  • If yes
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
  • Yes No
  • If yes
  • Are you on a special diet?
  • Yes No
  • Do you use tobacco?
  • Yes No
  • Do you use controlled substances?
  • Yes No
  • If yes
  • Women: Are you...
  • Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?
  • Are you allergic to any of the following?
  • Acrylic Aspirin Codeine Latex Metal Penicillin Sulfa Drugs Local Anesthetics
  • Do you have, or have you had, any of the following?
  • Yes No
    AIDS/HIV Positive
    Alzheimer's Disease
    Anaphylaxis
    Anemia
    Angina
    Arthritis/Gout
    Artificial Heart Valve
    Artificial Joint
    Asthma
    Blood Disease
    Blood Transfusion
    Breathing Problems
    Bruise Easily
    Cancer
    Chemotherapy
    Chest Pains
    Cold Sores/Fever Blisters
    Congenital Heart Disorder
    Convulsions
  • Yes No
    Cortisone Medicine
    Diabetes
    Drug Addiction
    Easily Winded
    Emphysema
    Epilepsy or Seizures
    Excessive Bleeding
    Excessive Thirst
    Fainting Spells/Dizziness
    Frequent Cough
    Frequent Diarrhea
    Frequent Headaches
    Genital Herpes
    Glaucoma
    Hay Fever
    Heart Attack/Failure
    Heart Murmur
    Heart Pacemaker
    Heart Trouble/Disease
  • Yes No
    Hemophilia
    Hepatitis A
    Hepatitis B or C
    Herpes
    High Blood Pressure
    High Cholesterol
    Hives or Rash
    Hypoglycemia
    Irregular Heartbeat
    Kidney Problems
    Leukemia
    Liver Disease
    Low Blood Pressure
    Lung Disease
    Mitral valve Prolapse
    Osteoporosis
    Pain in Jaw Joints
    Parathyroid Disease
    Psychiatric Care
  • Yes No
    Radiation Treatments
    Recent Weight loss
    Renal Dialysis
    Rheumatic Fever
    Rheumatism
    Scarlet Fever
    Shingles
    Sickle Cell Disease
    Sinus Trouble
    Spina Bifida
    Stomach/Intestinal Disease
    Stroke
    Swelling of Limbs
    Thyroid Disease
    Tonsillitis
    Tuberculosis
    Tumors or Growths
    Ulcers
    Venereal Disease
    Yellow Jaundice
  • Have you ever had any serious illness not listed above?
  • Yes No
  • If yes
  • To the best of my knowledge, the questions on this form have been correctly answered. I understand that providing incorrect information can be dangerous to my (or the patients) health. It is my responsibility to inform the dental office of any changes in my medical status.
  • Signature of Patient, Parent or Guardian:
  • Date

  • Clayton M. Hamilton, DDS      Trevor Hamilton, DDS
    Hamilton Dental, 7121 Chimney Corners, Austin, TX 78731
    Phone (512) 345-2170       Fax (512) 345-6356
Dental Insurance
Welcome to our practice.
Please take your time to fill out this form completely. The more we
learn about you, the better personal care we are able to provide. We look
for-ward to working with you to maintain a healthy, happy smile.
  • Primary Dental Carrier
  • Insurance co. name
  • Insurance co. phone
  • Address (Street, City, State, ZIP)
  • Group no. (Plan or Policy no.)
  • Insured's I.D. no.
  • Insured's name
  • Relationship to patient
  • Date of birth
  • Insured's social security no
  • Insured's employer name
  • Is insured a patient in our practice?
  • Yes No
  • Secondary Dental Carrier
  • Insurance co. name
  • Insurance co. phone
  • Address (Street, City, State, ZIP)
  • Group no. (Plan or Policy no.)
  • Insured's I.D. no.
  • Insured's name
  • Relationship to patient
  • Date of birth
  • Insured's social security no
  • Insured's employer name
  • Is insured a patient in our practice?
  • Yes No
  • Person Financially Responsible for Account
  • Name
  • Relationship to patient
  • Social security no.
  • Phone
  • Driver's license no.
  • Date of birth
  • Address (Street, City, State, ZIP)
  • Employer
  • Work phone
  • Preferred payment method:
  • Cash Credit Card
  • If patient is a minor, name of parent or legal guardian and relationship
  • Is this parent or legal guardian currently a patient in our office?
  • Yes No
  • With whom may we discuss your treatment other than your insurance company and Medical/Dental professionals?
  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
  • *You May Refuse to Sign This Acknowledgement*
  • I, , have received a copy of this office's Notice of Privacy Practices
  • Please Print Name
  • Patient signature
  • Date:


  • Person to contact in case of emergency
  • Name
  • Relationship
  • City
  • State
  • Cell Phone
  • Home phone
  • Work Phone
  • OFFICE USE ONLY
  • I VERBALLY REVIEWED THE MEDICAL / DENTAL INFORMATION ABOVE WITH THE PATIENT NAMED HEREIN
  • Date

  • www.HamiltonDentalAustin.com

Health History Update

  • Today's date
  • Patient Number
  • First name
  • Middle name
  • Last name
  • Address
  • City
  • State
  • Zip
  • Home phone
  • Work phone
  • Cell phone
  • Email
  • Anything else we should know?
  •  
  •  
    • Health Changes since last vist:
    • Date health change occurred
    • Physician's Name
    • Physician's Phone
    • Current Medications:
    • Last physical exam
    • Any Allergies
    • Patient Signature
    • Staff initials
    • Date
  •  
  •  
    • Health Changes since last vist:
    • Date health change occurred
    • Physician's Name
    • Physician's Phone
    • Current Medications:
    • Last physical exam
    • Any Allergies
    • Patient Signature
    • Staff initials
    • Date
  •  
  •  
    • Health Changes since last vist:
    • Date health change occurred
    • Physician's Name
    • Physician's Phone
    • Current Medications:
    • Last physical exam
    • Any Allergies
    • Patient Signature
    • Staff initials
    • Date
  •  
  •  
HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT FORM FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES
CONSENT/LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
  • Date:
  • Patient Name:
  • HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM RECEPTION AREA:
  • First Name Only Proper Surname
  • Other
  • PLEASE LIST ANY OTHER PARTIES WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE AND 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 Confirmation Email Confirmation
    Text Message to my Cell Phone Work Phone Confirmation
    Home Phone Confirmation Any of the Above
  • I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:
  • Cell Phone Confirmation Email Confirmation
    Text Message to my Cell Phone Work Phone Confirmation
    Home Phone Confirmation Any of the Above
  • I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:
  • Phone Message Any of the Above
    Text Message None of the Above (opt out)
    Email
  • 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.
  • 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.

  • Please print name of Patient
  •  
  • Please sign Patient / Guardian of Patient

  • Legal Representative / Guardian

  • Relationship of Legal Representative / Guardian
  • OFFICE USE ONLY
  • As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because:
  • ___ It was emergency treatment
  • ___ I could not communicate with the patient
  • ___ The patient refused to sign
  • ___ The patient was unable to sign because
  • ___ Other (please describe)
  • Signature of Privacy Officer __________________________________

HAMILTON DENTAL
712.1 Chimney Comers Austin, TX 78731 (512) 345-2170
Fax: (512) 345-6356
info@hamiltondentalaustin.com
AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION
  • Patient name
  • Patient number
  • Patient address
  • Patient phone number

I authorize the professional office of my dentist named above to release health information identifying me [including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services] under the following terms and conditions:
  • 1. Detailed description of the information to be released:
  • 2. To whom may the information be released [name(s) or class(es) of recipients]:
  • 2. To whom may the information be released [name(s) or class(es) of recipients]:
  • 3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):
  • 4. Expiration date or event relating to the individual or purpose for the release:

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

[For marketing authorizations, include, as applicable: We will receive direct or indirect remuneration from a third party for disclosing your identifiable health information in accordance with this authorization.]

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
  • Dated
  • Patient signature

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
  • Relationship to Patient
  • Print Name
Please enter code above in the field below.