375 Sixth Street

Dover, NH 03820

Tel (603) 749-0636 www.howarddental.com

Hello from JD Howard Dental!

On behalf of all the staff, we welcome you to our office. We are pleased that you have selected us to care for your dental

needs. We want you to know that we are committed to providing you the highest quality of oral health care in the most

gentle, efficient and caring manner possible.

During your first visit, scheduled for 90 minutes, we will conduct a thorough examination. This examination will include

necessary x-rays and other tools to help us make an accurate diagnosis of the condition of your mouth, teeth and gums. If

you have current x-rays (that are less than 5 years old) with your previous dentist, please obtain those records before

this initial appointment, or we will need to take new ones at your expense if insurance does not cover them again. In

most instances, we will determine your dental needs and then discuss the suggested treatment with you. After the exam

and screenings you will receive a treatment plan for any work that needs to be done so you will have a good estimate of

what your out-of-pocket will be if you were to schedule something. Generally, we don’t get to a cleaning. As always,

your personal health information will be kept private in accordance with HIPAA Privacy regulations.

We will strive to always be on time for you, except as emergency situations arise. We will appreciate the same courtesy. If

you do need to cancel your appointment we need at least 2 business days so that we have enough time to reschedule

your opening in the schedule; otherwise a $50 fee will be charged to your account (unless you paid the $50 deposit- that

would be used).

Our operatories are not big enough for children to remain with their parent. Due to the sensitivity of our dental equipment

and liability & safety issues, we ask that you have your child(ren) under the age of 10 stay in the waiting room with adult

supervision. Children over the age of 10 must be able to stay in the waiting unsupervised.

Enclosed you will find a Health History questionnaire. Please read and complete it and bring it with you to your first

visit. Should you have dental insurance, please bring your insurance identification card with you.

For your convenience, you can log onto www.howarddental.com for directions to our office, latest practice news and

dental tips. You can also e-mail us at frontdesk@howarddental.com with any non-emergency questions or concerns. We

make it a priority to respond to e-mail the same day or within 24 hours.

If you have any questions, or in case of an emergency, you may call us at (603)749-0636. We are looking forward to a

relaxed and pleasant visit with you!

Sincerely,

Joshua D. Howard, DMD and Associates

P.S. Please don’t forget to obtain your updated x-rays from your previous dentist.

Welcome to JD Howard Dental Please complete both sides. Thanks!

About You

Today’s Date:

Email address: □ I would like to receive email correspondences

□ I would like to receive text correspondences

□ I would like to receive phone correspondences on my cell,

home, OR work #. (Please circle only one.)

Name: First Last MI

I’d prefer to be called: Sex: ○ Female ○ Male Birth date: Social Security #:________________ Address:

City, State, Zip:

Home #: Work #:

Cell #: (needed for texts)

○ Married ○ Single ○ Divorced/Separated ○ Widowed

Your Employer:

Employer’s address:

City State Zip

For College Students:

College Name:

School Address:

City State Zip

Full time or part time student? (please circle one)

How did you hear about us?

Person responsible for account?

Primary Dental Insurance:

Do you have dental coverage? ○ Yes ○ No

Relationship to Insured: ○Self ○Spouse ○Child ○ Other

Insurance Company Name:____________________________

Address:__________________________________________

__________________________________________________

City State Zip

Insurance Co. Phone #:

Group #:

ID/Subscriber #:

Insured’s Social Security #:

Insured’s Birth date: ______/______/______

Insured’s Employer:_________________________________

Employer’s Address:_________________________________

__________________________________________________

City State Zip

Do you have a secondary dental insurance? ○ Yes ○ No

Relationship to Insured: ○Self ○Spouse ○Child ○ Other

Insurance Company Name:____________________________

Address: __________________________________________

__________________________________________________

City State Zip

Insurance Co. Phone #:

Group #:

ID/Subscriber #:

Insured Social Security #:

Insured Birth date: ____/____/____

Insured Employer:___________________________________

Employer’s Address:_________________________________

__________________________________________________

City State Zip

Payment is due in full at the time of treat-

ment.

See Financial Agreement for more info.

Spouse Information

His / Her Name:

Employer:

Work #: ( ) Ext:

SS#: D.O.B_____/_____/_____

Emergency Contact

His / Her Name:

Relation:

Home #: ( ) Cell #:( )

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have,

or medication that you may be taking, does have an important interrelationship with the dentistry you will receive.

Who is your primary care physician? Dr’s Name: _______________________ Phone #: Have you ever been hospitalized or had a major operation? ○ Yes ○ No If yes, please explain: Have you ever had a serious head or neck injury? ○ Yes ○ No If yes, please explain: Are you taking any medications, vitamins, herbal supplements, or drugs? ○ Yes ○ No If yes, please list:

Do you take, or have you taken, Phen-Fen, Fosamax, Boniva or Redux? ○ Yes ○ No Are you on a special diet? ○ Yes ○ No

Do you use tobacco? ○ Yes ○ No Do you use controlled substances? ○ Yes ○ No

Do you need an antibiotic before dental treatment? ○Yes ○ No If yes, please explain: ________________________________________

Are you allergic to any of the following?

○ Aspirin ○ Penicillin ○ Codeine ○ Acrylic ○ Metal ○ Latex ○ Dental Anesthetics ○ Sulfa Drugs ○ Erythromycin

○ Other:

CHECK ALL THAT APPLY:

Have you ever had any serious illness not listed above? Yes No If yes, please explain:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be

held in the strictest confidence and it is my responsibly to inform JD Howard Dental of any changes in my medical status. I authorize the dental

staff to perform any necessary dental service that I may need during diagnosis and treatment, with my informed consent.

Signature: Date:

Dental History Do you floss daily? ○ Yes ○ No Type of bristles on your toothbrushes? ○Hard ○Medium ○Soft

How often do you brush? Have you ever had gum treatment? ○ Yes ○ No Do any of your teeth move? ○ Yes ○ No

For office

use only: Dr’s Initials

Hyg./Assist

Initials

Our Office Policies

Insurance: As a courtesy to our patients, we will submit all claims to your insurance company. We do our best to

determine covered benefits & expenses. However, because each policy is different, it is ultimately up to the patient

to check with their insurance to determine the covered and allowed benefits. Any portion of treatment not cov-

ered by the insurance is the responsibility of the patient. We are in network with Delta Dental and Cigna. Any

other insurance is considered Out of Network, but we will submit the claim for you.

Estimates: We do our best to determine an estimate of your insurance benefits based on the recommended treat-

ment and the information provided by your policy. Please note that these amounts are estimates done to the best

of our knowledge and ability, coverage and benefits may vary depending on the determination of the insurance

company.

Payment: All deductibles, co-pays, and patient portions determined to be not covered by insurance are due at the

time of service. Patients without insurance are expected to pay for treatment in full at the time of service.

Payments: We accept cash, check*, money order, Visa, Mastercard, and Discover. As a courtesy our office offers

CareCredit as a type of payment plan. If you are interested in using CareCredit as a type of payment, please ask a

team member for more information or go online to www.carecredit.com.

*There is a $30 charge for returned checks.

Delinquent Accounts: Should your account be in delinquency for over 60 days, it will be placed into collections.

The patient is responsible for the legal and collection fees, as well as the total amount owed toward the account,

and any interest it has acquired. The patient will not be seen in our office until the account is in good standing. If

you are experiencing financial hardship and fear your account cannot be paid at this time, please contact our of-

fice manager.

Broken Appointments: Our office reserves the right to charge a fee of $35-$50 for any broken or missed appoint-

ment, depending on the length of time reserved for the appointment. This must be paid before your next appoint-

ment. Please give us 2 business days notice if you cannot make an appointment. If multiple appointments are bro-

ken or missed we reserve the right to dismiss you from our practice.

I have read, understood and agreed to the above policy for patient financial obligations. I understand that as

part of the HIPAA Privacy Notice my account may be discussed by employees of JD Howard Dental, LLC with

insurers, collection agents, 3rd party billing services or legal entities. I understand that the care rendered to me

by the doctor is based on my dental needs and I am responsible for the payment of those services. As a courtesy

to me, the office team will assist in maximizing my dental insurance benefits and will process the insurance

claims. However, I know that I am responsible for any services not covered by the insurance company.

(Please Print Patient’s Name) (Please Print Name of Responsible Party)

Signature of Responsible Party (Parent/Guardian if Patient is a Minor) Date

CONSENT TO DISCUSS TREATMENT AND ACCOUNT

I hereby authorize the following person(s) to have access to my account and to discuss any treatment in my

chart.

____________________________________ ____________________________

(Name) (Relationship)

____________________________________ ____________________________

(Name) (Relationship)

____________________________________ ____________________________

(Name) (Relationship)

Patient’s Name ____________________________________

Patient/Guardian's Signature ____________________________________

Date ____________________________________

Patient Smile Evaluation Form

Name:____________________________________________ Date:________________

To aid in our diagnosis and treatment of your esthetic concerns, please take a moment and answer the following

questions. Please circle your answer.

Do you want whiter teeth? YES NO

Do you have spaces between your teeth that bother you? YES NO

Do you have chips or uneven edges on your teeth? YES NO

Do you feel that your teeth are too long or too short? YES NO

Do you have dark fillings that show when you smile? YES NO

Do your gums show too much when you smile? YES NO

Are your teeth crowded or crooked? YES NO

Do you have existing crowns or dental work you consider “ugly”? YES NO

Are you self-conscious of your teeth and/or smile? YES NO

Has anyone (family member, friend, etc.) ever suggested that you

should have something done with your teeth or smile? YES NO

Do you avoid smiling when you have your picture taken? YES NO

Would you like to improve your existing smile? YES NO

Do you wake up in the morning with headaches? YES NO

Do you snore? YES NO

Have you ever been diagnosed with Sleep Apnea? YES NO

Have you ever had or thought about having Botox or Dermal Fillers? YES NO

Place a checkmark next to which of the following are concerns you have regarding dental treatment to improve

your smile:

Fear of treatment

Length of treatment time

Scheduling treatment concerns

Financial concerns

Distance to office

Not understanding treatment

Embarrassment

Other___________________________________________________________________

VELscope Oral Cancer Screening System Consent Form

What every person should know about oral cancer:

Oral cancer has 3 times as many victims as cervical cancer.

One American dies of oral cancer every hour of everyday.

The incidence of oral cancer is growing.

The biggest growth in oral cancer is among young non-smokers, and oral cancer is now linked to HPV.

When oral cancer is discovered in early stages, the survival rate is very high, but when discovered late (which

is normally the case), the survival rate is very low.

What are some of the risk factors for oral cancer:

Age, as most of the time it occurs in those over the age of 40.

Tobacco Use

Heavy Alcohol Use

Exposure to UV light (sun and tanning bed)

Viruses and fungi

Diets low in fruits and vegetables

Because of the risk of oral cancer to your health our practice has recently invested in a state-of-the-art

VELscope system. In addition to our conventional oral cancer examination, it can literally help us discover poten-

tially dangerous tissue that we might otherwise miss. Of course, the odds are that we won’t find anything. That’s

what concerns us. The VELscope system will increase our odds of finding it early rather than later.

What if the VELscope exam finds something?

In most cases, the VELscope exam will indicate that there is nothing to worry about. However, it is of course possi-

ble that some suspicious areas could be revealed. In that case, it could very well be that the suspicious-looking area

is of little or no concern, such as if it is caused by chewing the inside of your cheek or by irritation from dentures or

braces. If necessary, we may ask you to come back in a few weeks so that we may take another look. There is no

charge for this additional VELscope exam. If the area has improved in the meantime we’ll know that oral cancer

was not involved. If the area has not improved, we will photograph the area and refer you to an oral surgeon for an

additional evaluation, which may include a biopsy.

What is the cost of VELscope exam?

An oral cancer examination with a VELscope screening takes very little time, involves no pain or inconvenience and

is very affordable at $45. Some insurance companies are covering this oral cancer screening. Please inquire with

Rebecca, our Hygiene Coordinator, to see if your insurance covers this new service.

Consent- I hereby consent to allow JD Howard Dental, LLC to use the VELscope screening system as an additional

oral cancer-screening tool. If my insurance does not cover all or any of this screening tool I am financially responsi-

ble.

__________________________________________________ ________________________

Signature Date

__________________________________________________

Print Name

Optional

Failed/Cancelled Appointment Policy

Due to the increased number of failed appointments and appointments cancelled without

2 business days’ notice, we feel the need to implement this policy as follows:

1st Failed/Cancelled Appointment: You will receive a phone call stating you failed/cancelled

your appointment. A note will be made in your account.

2nd Failed/Cancelled Appointment: You will receive another phone call stating you

failed/cancelled your appointment again; a $35/$50 (depending on type of appt.)

Failed/Cancelled Appointment fee will be charged; and a note will be added to your account.

This charge must be paid in full in order to schedule any future appointments. This can be done

over the phone with a credit card for your convenience.

3rd Failed/Cancelled Appointment: You will receive another phone call, another $35/$50

Failed/Cancelled Appointment charge that must be paid in full before re-scheduling, and a note

will be added to your account. You may be discharged from the practice at this time.

JD Howard Dental, LLC

375 Sixth St., Dover, NH 03820

Health Insurance Portability and Accountability Act of 1996

Notice of Privacy Practices Effective April: 14, 2003 Last Modified: July 10, 2012