Our Office
Treatments
Dr. Fred Luedtke
The Team
The Cottage
Forms
Payment Methods
Code of Ethics
Contact Us
Contact Us
Testimonials
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1260 South 500 West
Bountiful, UT 84010
(801) 294-6174
Your Custom Text Here
Our Office
Treatments
Dr. Fred Luedtke
The Team
The Cottage
Forms
Payment Methods
Code of Ethics
Contact Us
Contact Us
Testimonials
Patient Information Forms
COVID-19 Questionnaire
COVID-19 Questionnaire
Name
*
First Name
Last Name
Email
Phone
*
(###)
###
####
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
*
Yes
No
Are you/they having shortness of breath or other difficulties breathing?
*
Yes
No
Do you/they have a cough?
*
Yes
No
Any other flu-like symptom, such as gastrointestinal upset, headache or fatigue?
*
Yes
No
Have you/they experienced recent loss of taste or smell?
*
Yes
No
Are you/they in contact with any confirmed COVID-19 positive patients?
*
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Yes
No
Is your/their age over 60?
*
Yes
No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
*
Yes
No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (As relevant to your location)
*
Yes
No
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
*
I understand.
Thank you!
New Patient Information Form
New Patient Information Form
Patient Information
Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.
Title:
Mr
Ms
Mrs
Patient Name
*
First Name
Last Name
Birth Date:
*
MM
DD
YYYY
Social Security Number:
Email
Main Phone:
*
(###)
###
####
Alternate Phone:
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
Whom may we thank for referring you to our practice?
Dental Office
Internet
Newspaper
Work
Other
Name of person, office, or other source referring you to our practice:
Spouse or Responsible Party Information
The Following is for:
The Patient's Spouse
The Person responsible for payment
Neither. Not applicable
Name:
First Name
Last Name
Gender:
Male
Female
Family Status:
Married
Single
Child
Other
Birth Date:
MM
DD
YYYY
Email Address:
Phone
(###)
###
####
Best time to call:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment Information
The following is for:
The Patient
The person responsible for payment
Employer Name:
Phone:
(###)
###
####
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Dental Insurance Information
Name of Insured:
First Name
Last Name
Insured's Date of Birth:
MM
DD
YYYY
ID #:
Group #:
Insured's Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insured's Employer Name:
Employer Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient's relationship to insured:
Self
Spouse
Child
Other
Insurance Plan Name:
Insurance Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
By Checking This Box:
I authorize the dentist to release any information, including diagnosis and the records of any treatment during the period of such dental care, to third party payers and/or health care practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for the payment of all services rendered on the behalf of my defendants.
Secondary Dental Insurance Information
Name of Insured:
First Name
Last Name
Insured's Birth Day:
MM
DD
YYYY
ID #:
Group #:
Insured's Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insured's Employer Name:
Employer Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient's Relationship to insured:
Self
Spouse
Child
Other
Insurance Plan Name:
Insurance Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
By checking this box
I authorize the dentist to release any information, including diagnosis and the records of any treatment during the period of such dental care, to third party payers and/or health care practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for the payment of all services rendered on the behalf of my defendants.
Medical History
Indicate which of the following you have had or have at present. By checking the box it will indicate a "Yes" response, leaving black will indicate a "No" response. Please explain below any "Yes" response.
Pre-Med
Alcohol/Drug Abuse
Allergy-Aspirin
Allergy-Codeine
Allergy-Epinephrine
Allergy-Erythro
Allergy-Lortab
Allergy-Penicillin
Allergy-Sulfa
Allergy-LATEX
Allergy-Other
Anemia
Anxiety Attacks
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Blindness
Blood Disease
Cancer
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Excessive Bleeding
Head Injuries
Fainting
Glaucoma
Growths
Handicap
Heart Disease/Attack
Hearth Murmur
Hemophilia
Hepatitis
Herpes/Fever Blister
High Blood Pressure
HIV/AIDS
Hospitalized
Jaundice
Kidney Disease
Liver Disease
Lupus
Mitral Valve Problems
Osteoporosis
Other
Pacemaker
Psychiatric Problems
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Seizure
Shingles
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Thyroid Problems
TMJ Problems
Tuberculosis
Tumors
Ulcers
Venereal Disease
Check any that apply
Presently being treated for any other illnesses
A Smoker or Smoked Previously
FEMALE: Taking birth control
FEMALE: Pregnant or Nursday
Do you have any health problems that need further clarification? Please explain:
Have you been hospitalized within the past 2 years?
Are under the care of a physician now? Please Explain:
Are you taking any medications? Please list: If "No" please type non:
Have you had any difficulty with previous dental visits?
Reason for today's Dental Visit:
Date of last dental visit:
How often do you brush?
How often do you floss?
Do you:
Suck Thumb/Finger
Sub/Bite Lips
Bite Fingernails
Chew hard objects
Grind teeth
Clench jaw
Mouth Breathe
Chew gum
Chew tobacco
Thrust tongue
Consent for Services
As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made. Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1% (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. I understand that any fee estimate for this dental care can only be extended for a period of six of months from the date of the patient examination. In consideration for the professional services rendered to this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach or condition here under shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted here under. I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.
*
I have read the above conditions of treatment and payment and agree to their content.
Date:
MM
DD
YYYY
Relationship to Patient:
Response Date:
MM
DD
YYYY
Signature of patient, parents, or guardian:
Thank you!
Existing Patient Record Update Form
Existing Patient Record Update Form
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
Medical History
Check all that apply
Pre-Med
Alcohol/Drug Abuse
Allergy-Aspirin
Allergy-Codeine
Allergy-Epinephrine
Allergy-Erythro
Allergy-Lortab
Allergy-Penicillin
Allergy-Sulfa
Allergy-LATEX
Allergy-Other
Anemia
Anxiety Attacks
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Blindness
Blood Disease
Cancer
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Excessive Bleeding
Head Injuries
Fainting
Glaucoma
Growths
Handicap
Heart Disease/Attack
Hearth Murmur
Hemophilia
Hepatitis
Herpes/Fever Blister
High Blood Pressure
HIV/AIDS
Hospitalized
Jaundice
Kidney Disease
Liver Disease
Lupus
Mitral Valve Problems
Osteoporosis
Other
Pacemaker
Psychiatric Problems
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Seizure
Shingles
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Thyroid Problems
TMJ Problems
Tuberculosis
Tumors
Ulcers
Venereal Disease
Thank you!
