Cambridge Dental Consultants

Dental Practice Management Articles

Blog By:
Kevin Tighe

NEW PATIENT CALL-IN FORM

DATE CALLED                                            APPT. DATE & TIME                                

PATIENT NAME                                                                                                                

IF PATIENT IS A CHILD, PARENT’S NAME                                                                 

HOME PHONE                                             WORK PHONE                                            

HOW DID YOU HEAR ABOUT OUR OFFICE?                                                              

WHEN WAS THE LAST TIME YOU SAW A DENTIST?                                               

ARE YOU HAVING ANY PROBLEMS WITH YOUR TEETH NOW?                          

DO YOU HAVE DENTAL INSURANCE?                                                                        

If yes, get the following information:

Name of the insured person                                        Relationship to NP                            

Employer of the insured                                             Emp. Phone #                                                    

SS# of the insured person                                           SS# of the patient                              

Name of Insurance Co.                                               Ins. Co. Phone #                                            

ACCOUNTS MANAGER: Verifies benefits and fills out before NP arrives.

Name of Insurance Company Rep.                                                                                       

Effective Date:                                                Max. benefits/year                                         

Deductible Amount                                        Has ded. Been met?                                       

Does deductible apply toward preventative?                                                                         

Percentage covered after deductible for-

Preventative                                                    Basic                                       Major            

Endodontics                                                    Periodontics                                                   

Frequency of Cleanings: (check one):

Two cleanings/year                                        
Once every six months                                   

Date of last cleaning                                       Date of last Full Mouth X-Ray                        

Do you replace teeth missing prior to effective date of coverage?                                        

Benefits left for the year?                                                                                                                                                                                                      

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