Patient Information (Complete ALL Sections!)

First Name

Middle Name

Last Name

Gender

Date of Birth

Age

Email (For Appointment Reminders)

Home Number

Cell Number

Work Number

Street Address

Apt #

City

State

Zip

Occupation

Employer

If you are a student are you part time or full time student?

Name of College Currently Attending

Upload photo ID

Spouse/Guardian/Emergency Contact (Complete ALL Sections!)

First Name

Middle Name

Last Name

Gender

Date of Birth

Age

Street Address

Apt #

City

State

Zip

Home Number

Cell Number

Work Number

What is this persons relationship's to you?

Occupation

Employer

Dental Coverage Information (Complete ALL Sections!)

Insured's Name (Person who carries the dental coverage)

Insured's date of birth

Insured's employer

Insured's Company Name

Insured's ID Number

Insured's ID Number (Cannot process claims without this. May be SSN.)

Group Number

Insurance Company Phone Number

Upload Insurance ID (Front)

Upload Insurance ID (Back)

Dual Coverage Information (For patients who have two dental plans.)

Insured's Name (Person who carries the dental coverage)

Insured's date of birth

Insured's employer

Insured's Company Name

Insured's ID Number

Insured's ID Number (Cannot process claims without this. May be SSN.)

Group Number

Insurance Company Phone Number

Upload Insurance ID (Front)

Upload Insurance ID (Back)

Appointment History (Complete ALL Sections!)

When were you last at the dentist?

Less then 1 year

More then 1 year

Never or NA

When were your last dental x-rays?

Less then 1 year

More then 1 year

Never or NA

Name of previous dentist?

Dental History (Please indicate, if applicable)

Do you regularly use dental floss?

Do your gums bleed when you brush or floss?

Have you had any periodontal (gum) disease?

Are you aware of any current dental problems?

Do you grind or clench your teeth?

Do you wear dentures or partials?

Are your teeth sensitive to heat, cold or pressure?

How did you hear about us?

Social media

Drive By

Phone

Friend

Family

Internet

TV

Medical Insurance

Dental Coverage Information (Complete ALL Sections!)

Insured’s Name

Insured’s date of birth

Insured’s employer

Insurance Company Name

Insurance ID Number

Insured’s ID Number Cannot process claims without this May be SSN

Group Number

Insurance Company Phone Number

Upload Medical ID (Front)

Upload Medical ID (Back)

Dual Coverage I nformation

(For patients who have two dental plans.)

Insureds Name Person who carries the dental coverage

Insured’s date of birth

Insured’s employer

Insurance Company Name

Medical Insurance ID Number

Insured’s ID Number Cannot process claims without this May be SSN

Group Number

Insurance Company Phone Number

Upload Medical ID (Front)

Upload Medical ID (Back)

Patient/Medical History

Medical History (Yes or No if you currently or have had any of the following conditions in the past.)

Heart Disease or Attack

Yes

No

Angina Pectoris

Yes

No

High Blood Pressure

Yes

No

Heart Murmur

Yes

No

Rheumatic Fever

Yes

No

Congenital Heart Lesions

Yes

No

Mitral Valve Prolapse

Yes

No

Heart Pacemaker

Yes

No

Heart Surgery

Yes

No

Artiﬁcial Joint (Hip, Knee)

Yes

No

Anemia

Yes

No

Stroke

Yes

No

Kidney Disease

Yes

No

Stomach Ulcers

Yes

No

Hepatitis A (Infectious)

Yes

No

Hepatitis B (Serum)

Yes

No

AIDS/HIV Positive

Yes

No

Liver Disease

Yes

No

Blood Transfusion

Yes

No

Yellow Jaundice

Yes

No

Drug Addiction

Yes

No

Alcoholism

Yes

No

Hemophilia

Yes

No

Epilepsy/Seizures

Yes

No

Glaucoma

Yes

No

Venereal Disease

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Radiation Therapy

Yes

No

Emphysema

Yes

No

Tuberculosis

Yes

No

Asthma

Yes

No

Sinus Pain/Drainage

Yes

No

Diabetes

Yes

No

Thyroid Disease

Yes

No

Arthritis

Yes

No

Cortisone Treatment

Yes

No

Psychiatric Treatments

Yes

No

Sickle Cell Disease

Yes

No

Sleep Apnea

Yes

No

Do you have any disease or problem not listed above?

Yes

No

If so please explain

Taken alendronate (Fosamax®), or risedronate (Actonel®)?

Yes

No

Being treated or treated in the past with intravenous bisphosphonates (Aredia®,Fosamax®,or Zometa®) for bone pain, hypercalcemia, or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Yes

No

Latex Allergy

Yes

No

Do you smoke?

Yes

No

Ready to quit?

Yes

No

NA

Currently under the care of a physician?

Yes

No

Name of physician:

Physician location:

Physician phone number:

Are you pregnant?

Yes

No

If so how many weeks?

Please list your medications:

Are you allergic to any medications

Yes

No

If so please list

Dental checklist

It is very important to us that we take care of your speciﬁc needs.
Please check either YES or NO to the things that pertain to you.

I have not been to a dentist in a long time and I’m worried about what you will tell me about my oral hygiene.

Yes

No

I am embarrassed with the way my teeth look.

Yes

No

I would like to see pictures and videos that will help me understand my dental problems

Yes

No

I have had a bad dental experience and have a lot of fear which has kept me from getting the dental care I need.

Yes

No

I am interested in achieving and maintaining good oral health.

Yes

No

I greatly fear going to the dentist.

Yes

No

I am interested in having a dental cleaning today.

Yes

No

I have a toothache and that is my biggest concern today.

Yes

No

I would like to replace my silver ﬁllings with tooth colored ﬁllings.

Yes

No

I am interested in a smile makeover.

Yes

No

I want to know more about teeth whitening.

Yes

No

I want to know more about straightening my teeth.

Yes

No

I snore or someone has told me I snore.

Yes

No

I currently wear a CPAP, but ﬁnd it uncomfortable and want an alternative device.

Yes

No

I suﬀer from migraines and want to know how the dentist can give me migraine relief.

Yes

No

I am interested in learning about ﬁnancing options so that I may be able to spread my payments out over time.

Yes

No

I do not have dental insurance and would like to know more about the Quality Dental Plan that Dr. Fryer’s oﬃce oﬀers..

Yes

No

Please add anything else you feel we should know in order to best serve you and your individualized needs

Consent for Treatment

I hereby certify that all above patient, medical, and dental information is correct and authorize Dr. Fryer and staﬀ to take x-rays, study models, photographs, or any other diagnostic aids seemed appropriate by Dr. Fryer to make a thorough diagnosis of my dental needs. I authorize Dr. Fryer to perform any and all kinds of treatment, medication, and therapy that may be indicated. If any conditions are discovered in the course of treatment which, in the opinion of the doctor require additional procedures or procedures diﬀerent than those described, I also authorize the performance of these procedures. I also understand that the use of anesthetic agents embodies a certain risk.

I understand that my dental insurance is a contract between me and the insurance carrier and NOT between the Doctor and that I am still fully responsible for all dental needs. These fees are due and payable at the time services are rendered unless prior ﬁnancial arrangements have been made. I also assign all insurance payments to the Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred.

I hereby state that I have read and understand this consent, and that all questions about the procedures have been answered to my satisfaction.
I consent for Kevin W. Fryer DDS Inc to send dental claims on my behalf (if applicable) and that the claim payment be sent to this oﬃce.

Warranty/Missed Reservation Policy

At Kevin W. Fryer DDS Inc., we pride ourselves on providing optimal dental health to all of our patients and their families. We stand behind our work, which is why we are happy to provide to you a 5 year warranty on a variety of services, something few other oﬃces oﬀer.

Our Part
If our sealants, composite ﬁllings, veneers, inlays, onlays, bridges, or crowns need replacement within 5 years, and the tooth is still restorable, we will replace the restoration of the same type, at no cost to you! All that we ask is you do your part in maintaining optimal dental health.

Your Part
If you brush and ﬂoss in the morning and in the evening daily, come to our oﬃce for your regular 6-month check-up, and complete all the recommended treatment at our oﬃce, you can prevent most or all disease. You must been seen at least twice a year (at our oﬃce) for a check-up to consider our warranty in eﬀect.

Missed Dental Reservation Policy

At Kevin W. Fryer DDS Inc, we pride ourselves on being prepared and ready for our patients. We kindly ask the same from you! If you ever need to reschedule a dental reservation with our oﬃce, there are many ways to reach our oﬃce-you can call us at 440-585-4200, email us at kwfryerdds@gmail.com, text us at 440-646-1004, or stop in.

If you are unable to make an appointment, we ask for a 48 hour notice to avoid a $50 fee.

Authorization and Consent to Use and Disclose Medical Information

The Medical Privacy Notice of Kevin W. Fryer DDS Inc provides information about how we may use and disclose conﬁdential medical information about you. You have the right to read our Notice before signing this consent. The terms of our Notice may change from time to time. If changed, we would inform you at your next visit.

By signing this Authorization, you agree to let us use and disclose conﬁdential medical information about you for treatment, payment, and dental oﬃce operations. This includes information about your dental health and medical health. You are also consenting to the release of health information about you to your insurer, third party, or other agents needed to get payment for your treatment.

E-Signature

Signature of Patient/Guardian
I have read the above warranty.
I have read the above policy.
I have read the above policy.

Clear Signature

Date

Patient Contact Information

Patient Information (Complete ALL Sections!)

Upload photo ID

Spouse/Guardian/Emergency Contact (Complete ALL Sections!)

Dental Coverage Information (Complete ALL Sections!)

Upload Insurance ID (Front)

Upload Insurance ID (Back)

Dual Coverage Information (For patients who have two dental plans.)

Upload Insurance ID (Front)

Upload Insurance ID (Back)

Appointment History (Complete ALL Sections!)

Dental History (Please indicate, if applicable)

Medical Insurance

Upload Medical ID (Front)

Upload Medical ID (Back)

Dual Coverage I nformation

Upload Medical ID (Front)

Upload Medical ID (Back)

Patient/Medical History

Medical History (Yes or No if you currently or have had any of the following conditions in the past.)

Dental checklist

Consent for Treatment

Warranty/Missed Reservation Policy

Missed Dental Reservation Policy

Authorization and Consent to Use and Disclose Medical Information

E-Signature

E-Signature Consent