New Patient + Screening

The Smile Enhancement Studio New Patient Form

We are honored that you have chosen us to care for your dental needs. We pride ourselves in making dentistry a pleasant experience and are committed to providing the highest quality oral health care in a friendly and efficient manner.

Our primary goal is to help you keep your teeth for a lifetime. Complete oral health care comprises not only the elimination of existing dental diseases but also the ultimate goal of prevention. We can reach this goal by keeping you informed so you can make educated decisions.

- The Smile Enhancement Studio

Patient Information
Name*
First Last
Sex*
- Male
- Female
Preferred Pronouns
Date of Birth*
YYYY dash MM dash DD
Same as Family Member
- Condense Form
Name of Family Member*
First Last
Mailing Address*
Street Address City Province Postal Code
Home Phone Number
Cell Phone Number
Work Phone Number
Email
Enter Email Confirm Email
Preferred Contact Method*
Preferred Cell Phone Method*
- Call
- Text
Occupation*
Retired From Occupation
- Retired From Occupation

Medical History

Thank you for taking the time to accurately fill out this medical history. Accurate completion of this helps ensure we diagnose and treat you appropriately.
Care Card Number
If under 18yrs of age, please enter BC Personal Health Care Number
Physician Name
Last Medical Visit
YYYY dash MM dash DD
Last Medical Visit
- Date Unknown
Reason for last medical visit.*
Do you take any prescription or non-prescription medications, herbs, vitamins or supplements?*
- No
- Yes
Please list any and all prescription and non-prescription medications, herbs, vitamins or supplements taken.
Medication Dosage
Medications List
Scan or Take a Picture of your medications list
Accepted file types: jpg, pdf, Max. file size: 8 MB.
Do you have any allergies to:
Check all that apply
- Local Anaesthetics
- Latex/Rubber
- Penicillin
- Other Antibiotics
- Sedatives or Sleeping Pills
- Iodine
- Other
List any and all additional allergies not listed above*
Please expand on your allergies.*
Have you ever been told that you require any prophylactic medications (eg: Antibiotics) prior to dental procedures?*
- No
- Yes
If yes, why?*
Do you (or did you ever) Smoke?*
- No
- Yes
How much and for how long?*
Do you (or did you ever) Chew Tobacco?*
- No
- Yes
How much and for how long?*
Do you (or did you ever) Use Controlled Substances?*
- No
- Yes
How much and for how long?*
Do you (or did you ever) Drink Alcohol in Excess?*
- No
- Yes
How much and for how long?*
Do you have any family history of disease?*
- No
- Yes
What diseases are in your family?*
Have you had any surgeries?*
- No
- Yes
What surgeries, and were there any complications?*
Are you pregnant?*
- No
- Yes
Are you nursing?*
- No
- Yes
Have you ever been tested for or been diagnosed with:
Check all that apply
- Heart Defect(s) Heart disease
- Lung or Breathing disease
- Liver disorder
- Metabolic disorder (ie: diabetes)
- Ears, Eyes, Nose, Throat disorders
- Genitourinary disorders
- Joint/Tissue Replacements
- Neuralgia/Paralysis
- Sleep disorders (Sleep Apnea, Insomnia, Upper Airway Resistance Syndrome)
Please explain diagnosis or test results*
Do you have a history of any major injuries or motor vehicle accidents?*
- No
- Yes
Please explain*
Do you have any medical conditions not noted above?*
- No
- Yes
If so, what?*
A large portion of our practice pertains to the treatment of chronic head, neck and shoulder pain. Are you interested in learning more about this unique and proven treatment?
- Yes, please

Dental History
Last Dental Visit
If unknown leave blank
YYYY dash MM dash DD
What was the reason for your visit?
What is your main reason for coming to The Smile Enhancement Studio?*
How did you hear about The Smile Enhancement Studio?*
Who referred you?*
What form of media?*
Where online did you hear about us?*
What kind of services are you looking for?*
If it was easy, would there be any changes you would make to your smile?*
Do you suffer from any form of daily or chronic pain in your body?*
Are you aware of any problems or are you concerned with anything in your mouth?*
- No
- Yes
If yes, please explain.*
Are there any limitations to you optimizing your oral health (ex. Financial, Time, Anxiety, etc)?
Do you suffer from dental anxiety?*
- No
- Yes
Have you ever been told that you:
Check all that apply.
- Grind your teeth
- Clench your teeth
- Snore
- Mouth breathe

Dental Benefits Information

By completing this section you hereby authorize Dr. Michael W. Burghardt Inc. to submit dental claims electronically on your behalf. Please also bring your benefits cards for your initial appointment.
Do you have dental benefits coverage?*
- No
- Yes
- Yes, but skip for now
- Yes, it is the same as a family member's
Whose information should be used?*
Primary Coverage
Insurance Card
Scan or Take a Picture of your insurance card
Accepted file types: jpg, pdf, Max. file size: 8 MB.
Name of Insured*
First Last
Date of Birth*
YYYY dash MM dash DD
Employer*
Phone Number
Insurance Company*
Group / Policy Number*
ID / Certificate#*
Maximum Coverage*
% Coverage A
% Coverage B
% Coverage C
Secondary Policy
Do you have any secondary coverage?
- Yes
Name of Insured*
First Last
Date of Birth*
YYYY dash MM dash DD
Employer*
Phone Number*
Insurance Company*
Group / Policy Number*
ID / SIN / Certificate#*
Maximum Coverage*
% Coverage A*
% Coverage B*
% Coverage C*

Almost Done!

If you think you entered anything in error, hit the 'previous' button to return to previous steps. You will not lose information you have entered by doing this.
Would you like to receive email updates & offers from The Smile Enhancement Studio?
- Yes, please
Office Policies

Our goal is to provide you, and your family, with the highest level of dental care, while maintaining a friendly, relaxing environment. Treating each other with kindness and mutual respect.

Our Cancellation Policy:

When clients give us advance notice of the need to reschedule their appointment, their time slot can be immediately allocated to clients who require urgent or emergency treatment. We appreciate your support in this matter.

If your appointment must be rescheduled, we require:
- A minimum 48 hours notice - please leave a message outside practice hours
If less than 48 hours notice is given, the following fees will be assessed:
- $75 for each ½ hr. scheduled provider time, ex. 1.5 hours = $225
  Please note - these fees are not covered by any dental insurance.
Insurance Benefits

With the recent implementation of the "Third Party Privacy Act", we are no longer able to obtain detailed information about your individualized plan. As a result, it is more productive when you deal directly with your insurance company to obtain the reimbursement of your benefits.

What this means to you:
- We optimize your dental treatment to ensure you receive the maximum benefits of your policy
- As a courtesy, we assist you in preparing and submitting the necessary forms
- You pay us directly for the full amount of treatment
- Because our office has an electronic claim filing system, most clients receive reimbursement within 2-5 business days
Our Payment Policy

Full payment is due upon completion of the prescribed treatment.
For your convenience, we offer a variety of payment methods - cash, debit, credit card, and third-party financing. We are confident that we offer a payment option that can accommodate every budget.

In order to assist you in the best way possible, we ask that you observe the aforementioned guidelines.

I have read the above policies and understand my client responsibilities.
Signature
If you are using a touch device, you can sign here, if not you can do so during your next visit.

Patient Screening & Risk Acknowledgement
Patient Name*
First Last
Who is completing this form?*
- Patient
Preferred Contact Method
- Phone
- Email

Do you have a fever or have felt hot, feverish or any Covid-19 symptoms anytime in the last two weeks?*
- Yes
- No
Comments
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?*
- Yes
- No
Comments

New Patient + Screening Form

Step 1 of 8 - Introduction

The Smile Enhancement Studio New Patient Form

Patient Information

Medical History

Dental History

Dental Benefits Information

Primary Coverage

Secondary Policy

Almost Done!

Office Policies

Our Cancellation Policy:

Insurance Benefits

Our Payment Policy

Patient Screening & Risk Acknowledgement

Medication	Dosage