Request an appointment

Fill out the quick form below and our team will confirm your appointment by phone. New patients always welcome.

FULL NAME *
PHONE NUMBER
EMAIL
PREFERRED DATE
DATE OF BIRTH
PREFERRED TIME
FIRST NAME
MIDDLE NAME
ADDRESS
CITY
STATE
ZIP CODE
GENDER
What pronouns do you use?
MARITAL STATUS
CELL PHONE
SOCIAL SECURITY NUMBER

IF THE PATIENT IS A MINOR, PLEASE PROVIDE THE FOLLOWING

PARENT OR GUARDIAN NAME
RELATIONSHIP
EMAIL
DOMICILIO
CITY
STATE
CELL PHONE
HOUSE PHONE
SOCIAL SECURITY NUMBER
WHO DOES THE MINOR LIVE WITH?

EMERGENCY INFORMATION

EMERGENCY CONTACT
PHONE NUMBER
RELATIONSHIP

MEDICAL HISTORY

The following questions are for your benefit and help ensure that any dental treatment takes your past and present health into account. Some questions may seem unrelated to your dental condition, but they are all connected to your oral health care. Please answer every question.

Have you taken any medication or drugs during the past two years?
Are you currently taking any medications, drugs, pills, or herbal remedies, including aspirin?
Are you sensitive or allergic to any substance or medication?
Have you ever taken prescription weight-loss medication (diet pills)?
Have you ever taken medication to treat or prevent osteoporosis, such as Fosamax, Actonel, Boniva, or a similar drug?
Have you been hospitalized in the past five years?
Have you ever had a serious head or mouth injury?
Have you ever been told to take premedication before dental treatment?
Is there anything else about having dental treatment that you would like us to know?
Do you have, or have you had, any disease, condition, or problem not listed above?
Have you lost or gained more than 10 pounds in the past year?
Do you have, or have you had, any disease, condition, or problem not listed above?
Please indicate which of the following you have had or currently have:
Are you currently nursing?
Are you pregnant or think you may be pregnant?
Are you taking prescription birth control?
Do you have any problems related to your menstrual period?

I have answered all questions to the best of my knowledge and understanding. If further information is needed, I authorize my health care provider or agency to be contacted, and they may release such information. I will notify the doctor of any change in my health or medications.

ACKNOWLEDGMENT AND CONSENT

Insurance Payment Authorization: *
I hereby authorize and direct payment of my dental insurance benefits directly to Mannheim Dental. If my insurance sends payment to me in error, I understand that I am responsible for forwarding said payment immediately. I understand that Mannheim Dental will, as a courtesy, submit a claim to my insurance. If for any reason my insurance denies payment, I am responsible for the full cost of my treatment.
Financial Responsibility Acknowledgment:
I agree to be responsible for payment of all services rendered to me or to my dependents. I understand that payment is due at the time of service unless other arrangements have been made. If payments are not made on the agreed dates, I understand that a $15 late fee may be added to my account. I also agree to notify Mannheim Dental of any change of address, phone number, or insurance within 30 days of such change. If I fail to meet these requirements, I authorize the use of all appropriate means, including credit history records, to locate my new address for collection purposes.
Notice of Privacy Practices *
I acknowledge that I have received information about the practice's privacy practices, which describes how the practice may use and disclose my health information for treatment, payment, health care operations, and other permitted uses and disclosures described therein. I understand that I may contact the privacy officer designated in the notice if I have any questions or complaints. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice's Notice of Privacy Practices.
Missed or Canceled Appointments *
If you are unable to attend your scheduled appointment, Mannheim Dental requires 24 hours' notice; otherwise, a $50 fee will be added to your account, and payment is due immediately. After three canceled or missed appointments without notice, Mannheim Dental reserves the right to terminate the patient/doctor relationship.