New Patient Forms

At our dental office in Grand Rapids, MI, we try to make the entire treatment process as comfortable and easy as possible for our patients. While this typically means offering quality dentistry from our skilled Grand Rapids dentist and excellent team, it also means finding ways to save you time. In order to be more efficient and reduce your wait time when you come to MI Roots Family Dental, we encourage you to fill out our patient forms before your visit. This will allow us to spend more time tending to your smile rather than your paperwork.

If you ever need assistance with your paperwork, don’t hesitate to give us a call at (616) 453-0002 ! You’re also welcome to reach out using our online contact form.

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Patient Information

Contact Information:

Please fill out all information to the best of your knowledge. All patient information will be kept confidential. If you have any questions, we will be happy to assist you.

Date:*

First Name:*

Last Name:*

I prefer to be called:

Gender:*

Male

Femeale

Date of Birth:*

Social Security #:

Mobile Phone:*

Home Phone/Other:

Email*

Patient Address:*

City:*

State:*

Zip:*

Marital Status:*

Married

Widowed

Single

Minor

Separated

Divorced

Partnered For (how many years?)

Other family members treated by us:

How did you hear about our office?*

Emergency Contact:

This should be the nearest relative who does not live with the patient, or a parent/guardian if the patient is a minor.

First Name:*

Last Name:*

Relationship to Patient:*

Mobile Phone:*

Home Phone/Other:

Email Address:

Person Responsible for Account:

**If the patient is responsible for their own account, please skip this section.

First Name:

Middle Name:

Last Name:

Relationship to Patient:

Date of Birth:

Social Security#:

Mobile Phone:

Home Phone/Other:

Email Address:

Occupation and Employer:

Billing Address:

City:

State:

Zip:

Insurance Information

If patient is uninsured, please sign the PHI Authorization before skipping to the next section.

Note: Insurance company information is usually included on the back of the member’s insurance card. If insurance company is Delta Dental of Michigan or Priority Health, you might not have received a card, in which case you may indicate “DDMI” in the phone and address boxes instead.

Primary Insurance:

Insurance Holders Name:*

Date of Birth:*

Relationship to Patient:*

Employer:*

Member ID:*

Group ID:*

Member ID:*

Name of Insurance Company:*

Insurance Company Phone #:*

Insured’s SSN#:*

Insurance Company Address:*

Insurance Company City, State, ZIP Code:*

Upload a photo of your Drivers License

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Upload a photo of your Insurance Card

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Does the patient have secondary insurance? If patient is uninsured or has primary insurance only, please sign the Authorization below before skipping to the next section.

Secondary Insurance: (If applies)

Insurance Holders Name:

Date of Birth:

Relationship to Patient:

Employer:

Member ID:

Group ID:

Name of Insurance Company:

Insurance Company Phone #:

Insured’s SSN#:

Insurance Company Address:

Insurance Company City, State, ZIP Code:

PHI Authorization:

All the above information is correct to the best of my knowledge. I authorize the use of this form on all my insurance submissions, and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Joseph Szymczak, DDS, PC dental practice to act as my agent in helping me to obtain payment from insurance companies. I authorize payment to Joseph Szymczak, DDS, PC dental practice. I permit a copy of this authorization to be used in place of the original. I give Joseph Szymczak, DDS, PC dental practice, its employees, and/or other agents express prior consent to contact me for the purpose of treatment, insurance, or payment.*

I have read, understand and agree to the terms and conditions of this PHI Authorization

Dental History

Preferred Pharmacy Name and Location:

Dental Concerns:

Please indicate any of the following problems that apply to you:

Tooth sensitivity (hot, cold, sweet)*

Yes

Tooth pain or discomfort when chewing*

Yes

Bleeding, swollen, or irritated gums.*

Yes

Grinding and clenching*

Yes

Loose or broken teeth*

Yes

Pain in jaw*

Yes

Frequent headaches, earaches, neck pain*

Yes

Have you ever had:

Bite plate or night guard*

Yes

Dentures*

Yes

Head injuries*

Yes

Oral surgery*

Yes

Orthodontic treatment*

Yes

Periodontal treatment*

Yes

Medical History

Medical History/Medications:

Please Select "Yes" or "No" to indicate if you are taking any of the following medications?

Painkillers (including aspirin)*

Yes

Blood thinners*

Yes

Insulin*

Yes

Meds for osteoporosis*

Yes

Please list all other medications:

Have you ever taken biphosphonates?*

These include alendronate (Fosamax), clododronate (Ostac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), tiludronate (Skelid), and zoledronic acid (Zometa).

Yes

Do you require antibiotic pre-medication for your dental work?*

Yes

Physician Name and Phone #:*

Do we have permission to contact your doctor regarding your care?*

Yes

Please Select "Yes" or "No" to indicate if you have had any of the following diseases, medical conditions, or procedures.

AIDS / HIV:*

Yes

Anemia:*

Yes

Arthritis, Rheumatism:*

Yes

Artificial Heart Valves:*

Yes

Artificial Joints:*

Yes

Asthma:*

Yes

Cancer/Tumors:*

Yes

Chemo/Rad. Treatment:*

Yes

Congenital Heart Defect:*

Yes

Diabetes/Hypoglycemia:*

Yes

Dizziness/Fainting:*

Yes

Eating Disorder:*

Yes

Emphysema/COPD*

Yes

Heart Attack/Stroke:*

Yes

Heart Disease:*

Yes

Heart Surgery:*

Yes

Hepatitis A, B, C*

None

High Blood Pressure:*

Yes

Low Blood Pressure:*

Yes

Kidney Disease:*

Yes

Liver Disease:*

Yes

Nervous Problems:*

Yes

Pacemaker:*

Yes

Pre-Medication:*

Yes

Psychiatric Problems:*

Yes

Respiratory Disease:*

Yes

Respiratory Disease:*

Yes

Rheumatic Fever:*

Yes

Scarlet Fever:*

Yes

Seizures/Epilepsy:*

Yes

Severe/Frequent Headaches:*

Yes

Sinus problems:*

Yes

Thyroid Problems:*

Yes

Tuberculosis:*

Yes

Allergies

Please indicate if you’ve ever had an adverse reaction or allergies to any of the following medications or substances:

Aspirin:*

Yes

Barbiturates (Sleeping Pills):*

Yes

Codeine:*

Yes

Dental anesthetics:*

Yes

Latex rubber:*

Yes

Penicillin/amoxicillin/antibiotics:*

Yes

Sulfa drugs:*

Yes

Please list all other allergies:

Have you been hospitalized or had any major surgeries in the last 10 years?*

Yes

Please list any other surgeries or medical conditions you have or have had:

Do you smoke recreationally? If No, please indicate “None of the above.” If yes, please indicate which of the following:*

Tobacco products

Marijuana/CBD products

None of the above

For Women:

Are You Pregnant?

Yes

Due Date:

Authorization:

I hereby certify that I have read and understand the previous information and that it is true and accurate to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payers, and/or healthcare practitioner.*

Accept Authorization

Financial Policy & Acknowledgement

The following information is to inform you of our financial policy. If, at any time, you have questions regarding this policy, please do not hesitate to ask any member of our staff.

We are committed to providing you with the highest quality level of care. Our fees reflect the quality of care we provide. We continue our commitment by offering a variety of financial options to enable you to receive the dental care you need. We accept cash, check, VISA, MasterCard, Discover, and American Express. We have also partnered with a third-party company to offer the flexibility of extended payment options.

We will communicate all recommended treatment options and associated fees prior to the start of treatment, if requested by the patient. Payment is expected at the time of treatment. A delinquent account impedes our ability to provide you with the quality dental care that you deserve. It is our policy that the parent or guardian who accompanies a child to our office for treatment is responsible for payment of all services rendered.

We are committed to respecting your time and ask that you make every effort to keep the appointment time reserved exclusively for you. We understand there may be times when you are unable to keep your scheduled appointment, however, any appointment missed may be subject to a missed appointment fee of $50. Should you find it necessary to reschedule an appointment, please provide us with notice of two business days (48 hours) to avoid being charged a missed appointment fee.

As a courtesy to our patients with dental insurance benefits, we will submit your claim and provide any necessary information to assist you in receiving your dental benefits. We require that any applicable deductibles and estimated patient portion be paid at the time treatment is rendered. It is ultimately the patient’s responsibility to work with and understand their insurance policy’s benefits and terms. It is also the patient’s responsibility to report any insurance changes to us. We do accept assignment of insurance benefits as a form of payment to help reduce your immediate out-of-pocket expense. We are a participating provider with Delta Dental only; all others are considered “out of network”. We do not participate with any adult or child Medicaid plans.

Please contact your insurance carrier prior to your visit to obtain essential information which will accurately reflect your coverage. Providing us with this information will expedite the processing of claims. If you have a direct reimbursement policy, payment in full is expected on the day of service and your dental plan will reimburse you.

Dental coverage is a contract between the patient and the insurance company. It is a benefit to assist you with the cost of dental care. At no time should insurance benefits compromise your doctor’s diagnosis or affect your choice of treatment.
It is your responsibility to understand the type of dental insurance you have (i.e. Traditional, Medicare, Medicaid) and the benefits selected by you and/or your employer.
You (not the insurance company) are responsible for the fees of services rendered.

I have read, understand and agree to the terms and conditions of this Financial Agreement.*

I have read, understand and agree to the terms and conditions of this Financial Agreement.

HIPAA Patient Consent Form

Please indicate below the names and contact information of anyone who might need access to your protected health information (ex. parents, spouses, medical advocates).

Name:

Relationship to Patient:

Phone #:

Name:

Relationship to Patient:

Phone #:

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPAA or The Healthcare Privacy Act). I understand that by signing this consent, I authorize Joseph Szymczak, DDS, PC dental practice to use and/or disclose my protected health information with the above-named individuals and to carry out the following:  Treatment which includes direct and/or indirect treatment by other healthcare providers.  Obtaining payment from third party payers, i.e. my dental and/or medical insurance companies.  The day-to-day healthcare operations of the dental practice. I have also been informed of and given the right to review and secure a copy of the practice's Notice of Privacy Practices (see the "New Patient Forms" section of the practice's website or ask for a copy at the front desk), which contains a more complete description of the uses and disclosures of my protected personal health information and my rights under HIPAA. I understand that the practice reserves the right to change the terms of this notice, and that I may at any time request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that the practice is not required to agree to use these requested restrictions. I understand that I may revoke this consent in writing at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.*

I have read, understand and agree to the terms and conditions of this HIPAA Patient Consent Form.

Consent for Treatment

I hereby authorize the doctor or designated staff to take X-rays, study models, photographs; and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient. Upon such a diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives, and other medications as necessary, unless otherwise indicated in my Medical History. I fully understand that using anesthetic agents embodies certain risks. I understand my right to ask for a complete recital of any possible complications.

Patients Full Name:*

Digital Signature:*

Todays Date:*

Rooted in the Community, Rooted in Your Care