GROUPON NEW PATIENT FORM

If you are a new patient, uploading your Driver’s License/Government Issued Photo ID will ensure the check-in process for your first appointment will be as quick as possible.

INSTRUCTIONS

1. With your smartphone, take a picture of the front and back of your Photo ID and Insurance Card prior to starting this form.

2. To upload your images, click the “Choose a file” button and locate "Photo library" on the image on your phone.

3. Do not use the “Take Photo or Video” feature within the form.

4. To ensure your images upload properly, take the photos BEFORE you start the form. Do not use the “Take Photo” feature within the form. Except in SELFIE UPLOAD BUTTON

Contact our office at 510-792-4525 (Newark)

if you have any questions. Or ask the Receptionist to help fill up these forms while waiting for your appointment

NOTE: Your files are fully encrypted with HIPAA-compliant software to ensure security and privacy.

Enter Full Name *

First

Last

Birthday *

Phone *

Patient E-mail *

Address / City / State / Zip Code *

Address Line 1

Address Line 2

City

State

Zip Code

Gender *

PLEASE SELECT FROM DROPDOWN MENU

Civil Status *

PLEASE SELECT FROM DROPDOWN MENU

Patient Alt. Phone #1

Alt. Phone#2

Patient Employer/ School *

Patient Employer/ School Phone *

Patient Employer/ School Address / City / State / Zip Code

Patient Spouse / Parent’s Name

Patient Spouse Employer

Patient Spouse Work Phone

Person to contact in case of emergency *

Phone to contact in case of emergency *

NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT *

Relationship to Patient *

PLEASE SELECT FROM THE DROP DOWN MENU

DO YOU HAVE GROUPON VOUCHER? *

YES

Reason for today’s visit *

Date of last dental care *

Former Dentist *

Date of last dental X-rays *

Previous Dentist Address *

How often do you floss? *

How often do you brush? *

Medical Physician’s Name *

Date of last visit *

Have you ever used a bisphosphonate medication? Common brand name are Fosamax, Actonel, Atelvia, Didronel, Boniva. *

Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No Have you had any serious illness or operations? If yes, describe *

Have you ever had a blood transfusion? If yes, give approximate dates *

(Women) Are you pregnant? Nursing?

Taking birth control pills?

Do you have a latex allergy? *

List medications you are currently taking and correlating diagnosis : *

Allergies: *

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. *

YES

I certify that I, and/or my dependent(s), have no INSURANCE AND WILL USE GROUPON. I have read the GROUPON fineprints and understand all the terms and conditions *

YES

Payment is due in full at time of treatment unless prior arrangements have been approved. *

YES

DATE SIGNED *

Date

Time

PLEASE TYPE OR ENTER NAME of Patient, Parent, Guardian or Personal Representative *

Signature *

ROTATE YOUR PHONE TO ENTER FULL SCREEN

PLEASE UPLOAD ANY GOVERNMENT VALID ID (FRONT) YOU CAN SKIP THIS BUT YOU MUST BRING YOUR ID CARD TO THE RECEPTIONIST!

Click or drag a file to this area to upload.

WAIT THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

PLEASE UPLOAD ANY GOVERNMENT VALID ID (BACK) YOU CAN SKIP THIS BUT YOU MUST BRING YOUR ID CARD TO THE RECEPTIONIST!

Click or drag a file to this area to upload.

WAIT THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

UPLOAD SELFIE

Click or drag a file to this area to upload.

WAIT THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

UPLOAD GROUPON VOUCHER. YOU CAN SKIP THIS BUT YOU MUST BRING YOUR VOUCHER TO THE RECEPTIONIST!

Click or drag a file to this area to upload.

WAIT THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

Updating preview…

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.