Managing Patients: The Patient Experience Guidelines for Pratctice Success. American Dental Association

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Text Home phone Work phone Email

      How did you hear about our office?

       Referral Website Signage Coupon Other: _________________________________

      Referral Source: ____________________________________________________________________________

      Are you experiencing any dental problems or have any dental concerns?

       Pain? Where?_______________________ Constant? Occasional?

       Swelling?Where?________________________

      Are you under the care of a physician? Yes No

      When was your last dental visit?_____________________ Are x-rays available? ______________________

      Name of previous dentist: __________________________ Phone number: ___________________________

      Address: __________________________________________________________________________________

      Do you have a dental benefit plan? Yes No

      If Yes:

      Member ID number: _______________________________Group number: ___________________________

      Name of policy holder: ______________________________________________________________________

      Policy holder’s relationship to the patient: ______________________________________________________

      Date of birth:______________________________________________________________________________

      Policy holder’s employer: ____________________________________________________________________

      Insurance company: _______________________________________________________________________

      Address: __________________________________________________________________________________

      Phone number and/or insurance company website: _____________________________________________

      Scheduled appointment date: ________________________________________________________________

      Verification of eligibility and benefits by: ______________________________________________________

       Electronic Fax Verbal

      Verification scanned, saved or written in record date: ___________________________________________

      Maximum benefits/year: $______________

      Deductible amount:$_______________

      Has deductible been met? Yes No

      Does deductible apply to preventive services? Yes No

      Determine frequency of preventive services:

       Twice per year

       Once every six 6 months

       Other: ______________________________

      Date of last radiographs: ___________________________________________________________________

      Prior tooth loss restrictions: _________________________________________________________________

      Any other restrictions or limitations: __________________________________________________________

      __________________________________________________________________________________________

      Benefits remaining for benefit year: __________________________________________________________

      Additional information:______________________________________________________________________

      __________________________________________________________________________________________

      © ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for legal or professional advice.

Office Hours and Time Management

      Every patient deserves the best care you can offer. While it might be tempting to schedule as many patients as possible, the goal of effective time management is to achieve a workable balance between quality and quantity. While a full schedule may be appealing, over-scheduling could make you feel pressure to rush through appointments. The quantity of dentistry can never outweigh the quality. Compromising the quality of patient care could risk the viability of your practice.

      Try to match your office hours to the

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