Patient Information

The first step towards a beautiful, healthy smile is to schedule an appointment. Prior to your first visit, Dr. Stevens would like the opportunity to review your medical and dental history. We kindly ask that you fill out and submit the online consent forms two business days before your appointment. Please don’t hesitate to contact our office should you have any questions.

Forms

Patient Consent
Form
Medical & Dental
Form
Handle me with Care
Form
Medical & Dental
Form

Medical & Dental Form

Please fully complete and return this form at least 2 business days prior to your visit as Dr. Stevens would like the opportunity to review your medical records.

Personal Information

Your Contact Information

Has your doctor ever indicated that you require an antibiotic before dental therapy?   
If yes, for what reason:

Do you smoke or chew tobacco products?
If yes, how much / many per day:
WOMEN: Are you pregnant or breastfeeding?
If pregnant, when is the expected date of delivery:

There is now a well-known link between gum disease and several significant medical conditions.

Please indicate any of the below that you have a family history of:

Do you have or have you ever had any of the following? Please check all that apply.

Please list and explain any disease, condition or problem not listed

Have you had any of the following? Please check all that apply

The National Highway Transportation Safety Administration estimates that over 100,000 crashes each year are caused by sleepy drivers. An estimated 50,000+ premature and preventable deaths may occur each year as a consequence of UNTREATED Obstructive Sleep Apnea. The most common terminal events are stroke, heart attack and accidents. Please answer the following questions by selecting the appropriate response to each situation, and we will calculate the results below.

How likely are you to doze off or fall asleep in the following situations (in contrast to just feeling tired)? Please score between 0 for “not at all” to 3 for “extremely likely”:

Please describe your normal home care for your teeth and gums.
Is there any information pertaining to your past dental or medical experiences that you feel we should know about that would better help us to individualize your care?
In order for us to be sensitive to your needs, please tell us of any unpleasant experiences you may have had related to oral care.

Dental insurance

Please note that the team at Dr. Andrea Stevens Dentistry will be more than happy to electronically submit your treatment to your insurance at time of payment. Payment is due at time of appointment. We have the ability to electronically submit to the primary insurance only, should there be secondary insurance you will be provided with a printed claim form which you will have to submit with the response from the primary insurance.

Primary Insurance

Secondary Insurance

Upon your first visit to Dr. Stevens’ office, you will be required to sign verifying that the information entered on these forms is correct to the best of your knowledge. This will also authorize Dr. Stevens and her team to contact your health care provider(s) concerning your treatment if necessary
Handle me with Care
Form

Handle me with Care Form

Please put a checkmark in the box next to the statement(s) that concern you:

This is a "Handle me with Care" partnership. Now that you understand the importance of communicating all your fears and any issues of embarrassment and trust, let us look at making a "Handle me with Care Pact" between you and your dental team.

The Pact: Our team will honestly inform you of all your dental problems. We will make you aware of the best quality dentistry available today. Then we can discuss how you can make healthy choices that will work within your budget. We will offer you all the pain relief options which are available to you in our dental office, inform you how each dental procedure will work, and how much of your time will be required. When the team at Dr. Andrea Stevens Dentistry recommends any treatment they will always inform you of all treatment options available and allow you to make a decision which makes you feel comfortable.

Personal Information

Financing and Insurance

The costs associated with enhancement dental procedures vary widely depending upon the type and complexity of the procedure. While the benefits of a new smile can be priceless, enhancement dental procedures can sometimes be costly. Don’t let the cost scare you, help is available.

Dental insurance can help cover a portion of your treatment but can be complex and should be looked into thoroughly before proceeding. Dental insurance is not medical insurance, where most medical insurance plans cover the entire cost of a treatment — with the patient contributing only a minimal co-pay — dental insurance rarely covers an entire procedure, especially for cosmetic reasons.

Dr. Stevens offers affordable payment options for her patients, which include payment by Visa, Mastercard, debit, or through a dental financing company such as Dental Card. The first step is to schedule an initial appointment to determine exactly what procedures are needed, and how much those procedures will cost. Dr. Stevens will then discuss your various payment options and work out a plan best suited for you.

As a paper-free office, we are also pleased to offer electronic transmission of insurance claims directly to insurance companies so you can receive your benefit in a timely manner.

Healthy Teeth Tips

Do you have questions? We’ve got answers!

FAQ