Saugus Dental Laser Center
661-297-7580Patient Form
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Patient Form

Welcome to Saugus Dental Laser Center. This form takes about 5 minutes and is kept confidential. Fill it in right here, then send it to the office or save it as a PDF and bring it along.

1 Patient InformationTell us who you are and how to reach you.

Is this visit for emergency dental care?

Emergency Contact

2 Insurance and PaymentWe are a provider for most major PPO plans. No card numbers are collected here.How Do You Plan to Pay?

Primary Insurance (skip if none)

Secondary Insurance (if any)

3 Medical HistoryThese questions assure your treatment takes your health into account. Answer what you can.

Are you in good health?

Are you currently under the care of a physician?

Have you ever had a serious illness, operation, or hospitalization?

Have you ever been premedicated with antibiotics for dental treatment?

Do you wear a pacemaker, or have you had heart surgery?

Do you smoke?

(Women) Are you pregnant?

Are You Sensitive or Allergic to Any of These?

Do You Have, or Have You Had, Any of the Following?

4 Dental HistoryNervous patients are our specialty. Be honest, it helps us help you.

Have you ever had a local anesthetic (Novocaine, etc.)?

Have you ever had an unfavorable reaction to a local anesthetic?

Have you had any serious trouble with previous dental treatment?

Would you like to discuss pre-sedation options?

Does Dental Treatment Make You Nervous?
5 Consent and SignatureThe short version of the paperwork, in plain language.

Financial arrangements. Treatment costs are agreed before treatment begins. If you carry insurance, our office helps prepare your insurance forms and credits collections to your account; you remain personally responsible for payment of all dental services. Emergency services and services without prior arrangements are paid at the time of treatment. Fee estimates are valid for six months from the date of examination.

Assignment of insurance. I authorize my insurance company to pay benefits accruing to me directly to the dentist under my policy.

Consent for treatment. I grant authority to the dentists in charge of the care of the patient named on this form to administer anesthetics, analgesics, and sedation, and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of possible complications of procedures, anesthetics, and drugs.

Accuracy. To the best of my knowledge, all answers on this form are true and correct. I will inform the doctor of any change in my health or medications at my next appointment.

Send to Office opens an email to appointment@saugusdental.com with your answers. Save as PDF gives you a clean copy to bring along or attach yourself.

🔒  This information is necessary for the practice's files and is considered confidential. It goes only to Saugus Dental Laser Center.

📞 Call 661-297-7580Patient Form