Form – Pre-Appointment New Patient Form | Vista Ridge Dental Arts Studio

Amy Moody, DDS

Vista Ridge Dental Arts Studio

108 West Tenth Avenue, Johnson City, TN 37604

Phone: 423.979.1800

Email: info@vistaridgedentalartsstudio.com

New Patient Information

Leave this blank

NAME: *

DOB: *

ADDRESS: *

CELL PHONE: *

WHOM MAY WE THANK FOR THE REFERRAL?

SSN (can be provided verbally in office if hesitant, used only for insurance purposes)

EMAIL: *

EMPLOYER:

PRIMARY INSURANCE COMPANY:

MEMBER/SUBSCRIBER #:

GROUP#

SUBSCRIBERS NAME (if not patient):

Subscriber DOB:

Subscriber SSN#:

(please include a photo copy of the insurance card, front and back)

Upload Primary Insurance Card - Front

Upload Primary Insurance Card - Back

Secondary Insurance Company:

Secondary Member #:

Secondary Group #:

Upload Secondary Insurance Card - Front

Upload Secondary Insurance Card - Back

ANY FAMILY MEMBERS SEEN BY DR. MOODY:

LAST DENTAL VISIT:

DENTIST:

HAVE YOU HAD X-RAYS WITHIN LAST 3 YEARS:

Yes No

(please sign the records release form if you wish for us to obtain those from your previous dentist); ***** some of the x-rays expire in 1 year and some not for 5 years; since they are necessary for the comprehensive exam we will retake all expired or unobtained x-rays in the office at time of visit)

ARE YOU CURRENTLY IN PAIN?? Please describe symptoms below:

AS WE REVIEW THE SCHEDULE FOR AVAILABILITY, DO YOU HAVE ANY DAY OR TIME PREFERENCES? IF YES, PLEASE NOTATE

*** New Patient forms are submitted to you for completion at home via text or email; please arrive 30 min prior to scheduled appointment if you prefer completing them in the office.