Justin W Dugas DDS   |   740.548.0575
Hours and Location 740.548.0575 New Patient Forms Schedule an Appointment

New Patient Form


Patient Registration


First Name Last Name Middle Initial
Patient Is:
Preferred Name

Responsible Party Information (if someone other than the patient)

First Name Last Name Middle Initial
Address Line 1
Address Line 2
City
State
Zip
Home Phone
Work Phone Ext.
Cell Phone
Birth Date
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SSN
Driver's License #

Patient Information

Address Line 1
Address Line 2
City
State
Zip
Pager
Home Phone
Work Phone Ext.
Cell Phone
Birth Date
v
Age
SSN
Driver's License #
Email
Referred By Previous Dentist
Emergency Contact Emergency Contact Number

Primary Insurance Information

Name of Insured
Relationship to Insured
Insured SSN
Insured Birth Date
v
Insurance Company
Subscriber ID
Group ID

Secondary Insurance Information

Name of Insured
Relationship to Insured
Insured SSN
Insured Birth Date
v
Insurance Company
Subscriber ID
Group ID

Medical History


PATIENT NAME Birth Date
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Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important relationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
If yes, please explain:
Have you ever been hospitalized or had a major operation?
If yes, please explain:
Have you ever had a serious head or neck injury?
If yes, please explain:
Are you taking any medications, pills, or drugs?
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Do you need to pre-medicate?
If yes, please explain:
Women:
Are you pregnant / trying to get pregnant?
Taking oral contraceptives?
Nursing

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Have you ever had any serious illness not listed above?
If yes, please explain:
Comments:

To the best of my knowledge, the questions in this section have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, OR GUARDIAN Date
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Appointments and Cancellations

When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please give us at least 48 hours notice. This courtesy makes it possible to give your reserved room to another patient who would like it.

We feel that our patients' time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you.

We understand that last minute schedule changes are sometimes unavoidable. When you make an appointment, we reserve time specifically for you. We have made a commitment to see you at that resereved time. When a patient misses an appointment, they often think that the doctor has many other patients waiting to be seen. When appointments are missed on short notice, or a patient fails to show up, three things happen:

  1. Treatment is delayed, which in some cases can allow a condition to worsen.
  2. Another patient who needed treatment cannot be seen.
  3. The doctor and staff must wait until the next scheduled patient arrives to resume work.

There is a $25 charge for missing or cancelling scheduled appointments during the week without providing 48 hours notice and a $50 charge for Saturday missed or cancelled appointments without providing 48 hours notice. We reserve the right to make exceptions to this policy based on the nature of each individual situation. Repeated cancellations or missed appointments will result in loss of future appointment privileges.

By signing below, I acknowledge that I have read and understand the missed appointments and cancellations policy of Dugas Dental.

Signature: Date:
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Method of Contact

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