New Patient | Studio B Smiles

Patient information

Full name *

I prefer to be called

Date of birth *

Sex

Marital status

Who referred you

Address

City

State

ZIP

Email *

Cell phone *

Home phone

Occupation

Employer

Social Security Number

Emergency contact

Name

Relation

Phone

Insurance

If you have dental insurance, add it here. You can leave this blank and we will help at your visit.

Dental insurance company

Subscriber name

Subscriber ID

Group number

Dental health

Last dentist seen

Current dental health

What is the primary reason for your visit?

Are your teeth somewhat yellowed, darkened or stained?

Have you ever experienced pain or discomfort in your jaw joint (TMJ/TMD)?

Are there spaces between any of your teeth?

Do you grind your teeth, or are biting edges chipped or worn down?

Do you have a gummy smile, or gums that are too thick?

Are your gums red, puffy, or do they bleed?

Do you have gray, black or silver fillings you want to replace?

Do you have old crowns with dark edges that do not look natural?

Are you currently experiencing any pain or discomfort?

Does food catch between your teeth?

Are your teeth sensitive to cold or sweets?

Any unpleasant experiences in a dental office?

Medical history

Tap any condition you have had. Leave the rest unselected.

Other conditions

Allergies

Taking any medications?

Pregnant or nursing?

Consent & signature

I authorize Dr. John Badolato and Studio B Smiles to perform the dental treatment, x-rays, photographs, and diagnostic procedures deemed appropriate. I understand that no specific result is guaranteed and that all treatment carries risks and alternatives, including no treatment, which have been made available for my review.

I accept full financial responsibility for services provided. Payment is due at the time of service, and a 1.5% monthly finance charge applies to balances over 30 days past due. I understand my dental insurance is a contract between me and my insurer, that Studio B Smiles assists with filing claims, and that any portion insurance does not pay is my responsibility.

I will give at least one business day notice to cancel or reschedule, and I authorize Studio B Smiles to use my health information for treatment, payment, and operations as described in the Notice of Privacy Practices. The information I have provided is accurate and complete to the best of my knowledge.

I have read and agree to the Patient Information and Practice Agreement and consent to treatment.Signature *

Sign above with your mouse or finger.

A copy will be emailed to you and sent to our front desk.

Welcome to Studio B.

Patient information

Insurance

Dental health

Medical history

Consent & signature