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Patient Demographic Form

Patient Information

Marital Status
Race (optional)

Physical Reference Information

Responsible Reference (Guarantor) Information

Relationship to Patient

Emergency / Next of Kin Contact Information

Primary Insurance Information

Secondary Insurance Information

Patient Medical History

1. Are you under medical treatment?
3. Have you ever been hospitalized for any surgical operation or serious illness?
4. Are you taking medication(s) including non-prescription medicine?
5. Do you have congenital heart disease, a heart valve replacement, or joint replacement?
6. Do you use tobacco?
7. Do you use alcohol?
8. Are you currently taking Aspirin, Plavix, Coumadin or any other blood thinners?
9. Are you currently taking Boniva or any other bone building drugs?
10. Do you use cocaine or other drugs?
11. Are you allergic to or have you had any reaction to any of the following?
Local Anesthetics
Sulfa Drugs

12. Women Only

A. Are you pregnant or think you may be?
B. Are you nursing?

13. Do you have or have you had any of the following?

Auto Immune Disease
Blood Disease
Chest Pain
Clench/Grind Teeth/TMJ
Easily Winded
Excessive Bleeding
Gerd (Reflux)
Head or Neck Injury
High/Low Blood Pressure
History of Heart Attack
History of Heart Disease
Kidney Disease
Liver Disease
Nervous Disorder
Respiratory (Lung) Problems
Rheumatic Fever
Sleep Apnea
Stomach Problems/Ulcers

I certify that I have read and understand the above information and, to the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

Financial Responsibility Clause

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account services for any professional services rendered. I also understand that all payment is due when services are rendered unless previous arrangements have been made. I also agree that should my account(s) be referred to any attorney or collection agency for collections, I will be responsible for all reasonable attorney fees, court costs and/or collection agency charges and expenses.

I agree that I will assume full responsibility for any court costs, attorney fees, collection agency fees and miscellaneous expenses involved in the legal collection of payment of this account. I further agree that I will at no time file a waiver of exemption against any type of legal seizure of personal property involved in the collection of delinquent payments. My signature affirms that I have read and understand the above agreement.

I give permission to apply any overpayment on this account to other outstanding balances with the same responsible party.

Consent to Wireless Telephone Calls

If at anytime I provide a wireless telephone number at which I may be contacted, I consent to receive calls (including autodialed calls and prerecorded messages) at that wireless number from Wilson Dental, its successors and assigns, and the servicer and collection agents, of each of them regarding the account, the services rendered, or my related financial obligations.

Notice of Privacy Practice Acknowledgment

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information, I understand that this information can and will be used to:

  • Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my personal requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Photo Consent

I give Wilson Dental, Inc., Patrick R. Wilson, D.M.D., permission to take intraoral photographs of my teeth and surrounding gum tissue and facial tissue. I give Wilson Dental, Inc., Patrick R. Wilson, D.M.D., permission to share/ use these photographs to share with staff and consulting doctors. I also give Wilson Dental, Inc., Patrick R. Wilson, D.M.D., permission to use these photographs on social media such as Wilson Dental, Inc. website, Facebook, Instagram, etc. I understand that at anytime I can request to have these photographs removed from social media and Wilson Dental, Inc., Patrick R. Wilson, D.M.D., will remove them. I also understand that one will not hold Wilson Dental, Inc., Patrick R. Wilson, D.M.D., at fault for my photographs on Facebook being shared by other people for which Wilson Dental, Inc., Patrick R. Wilson, D.M.D. cannot be deemed responsible, nor can they remove them once shared. Lastly, I understand that Wilson Dental, Inc., Patrick R. Wilson, D.M.D., has my best interest in mind and wants me to be proud and happy of my new smile.

Privacy Policy

As agreed in our Notice of Privacy Act, we must have permission to release your information. Please check the names below of who we can release your information to along with their names.

If we refer you to another office, do we have permission to release your information to that office?

Notice of Privacy Practices



The Health Insurance Portability & Accountability Act of1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act give you, the patient, significant rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

  • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include teeth cleaning services.
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.