Patient Forms

New Patient Registration

X-Ray & Records Release

Medical History

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Call the Office

859-291-7621

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Fax

859-291-0048

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Office Location

340 Fairfield Ave, Bellvue, KY 41073

Forms

New Patient Registration Form

New Patient Registration

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Dr. Kevin S. Wall
340 Fairfield Avenue
Bellevue, KY 41073
Phone:859-291-7621
Fax: 859-0048
Email: admin@kevinwalldmd.com

New Patient Form

Patient Information

*NameLast, First, Middle Initial

*Today's Date

Date of Birth

Social Security Number

*Home Phone

Cell Phone

*Address

*City

*State

*Zip Code

*Email

Marital StatusPlease select one of the following

Minor

Single

Married

Partnered

Separated

Divorced

Widowed

Patient's Employer

Work Phone

Job Status

Full Time

Part Time

Not Working (Self-Pay)

Employer Address

Employer City

Employer State

*Employer Zip Code

Spouse or Parent/Guardian's Name

Spouse's Employer

Spouse's Employer Phone Number

Whom May We Thank For Referring You?

Responsible Party

*Responsible Party's Name

*Responsible Party's Relationship to Patient

*Responsible Party's Phone Number

Responsible Party's Email

*Responsible Party's Birthdate

*Responsible Party's Social Security Number

Responsible Party's Employer

Responsible Party's Employer Phone

Dental Insurance Information

Name of Insured

Insured's Relationship to Patient

Insured's Birthdate

Insured's Social Security Number

Insured's Name of Employer

Insured's Work Phone

Payment MethodIn addition to insurance, for your convenience, we offer the following methods of payment. Please select the option you prefer.

Cash

Personal Check

Visa

MasterCard

Discover

AMEX

Care Credit

Insurance Company's Name

Group #

Member ID #

Insurance Company's Address

Insurance Company's City

Insurance Company's State

Insurance Company's Zip Code

Insurance Company's Provider / Customer Service Phone Number

Do You Have Additional Insurance?If yes, please let the front desk know.

Yes

Financial Options and Payment Agreements

Taking care of you and your family is our highest priority. That is why, when it comes to talking about finances, our goal is to provide you with clear information regarding our dental fees and your payment options. Please check the preferred payment plan for your family:

PLAN A: I do not plan to use dental insurance, and will be paying out of pocket.

PLAN B: I am interested or already a member of your Dental Savings Plan!

PLAN C: 6 month payment plan using a major credit card (MasterCard or Visa)

PLAN D: Care Credit is a 12 month, same-as-cash option, and our staff would be happy to assist you with the application process.

PLAN E: We will gladly bill your insurance plan, with your understanding that you will be responsible for the amount not covered.

*Authorized Patient's Name

have chosen

*Planfrom the above

above and accept full responsibility for this account. I understand that I am responsible for understanding my insurance benefits, if applicable. I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance. I understand that any insurance estimate given is not a guarantee of actual insurance payment or coverage. I also understand that I am responsible for all charges incurred for dentistry performed upon me and my dependents. Any insurance claim not paid in full after 60 days will become my responsibility at that time. In addition, I also agree to pay for all costs of collection, including attorney fees, and court costs, should additional means of collection be required.

Authorization and Release Agreement

In regards to my medical history, I certify that I have read and understand all of the information provided to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information, or not providing information, can be dangerous to my health.

*Patients Signature

*Date of Signature

HIPPA

Would You Like to Share Your Medical Information with Anyone?

Yes

Information Receiver's Name

Information Receiver's Phone Number

Information Receiver 2 Name

Information Receiver 2 Phone Number

*HIPPA Signature

*HIPPA Signature Date

Forms

X-Ray and Records Release Form

X-Ray Release Form

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Dr. Kevin S. Wall
340 Fairfield Avenue
Bellevue, KY 41073
Phone:859-291-7621
Fax: 859-0048
Email: admin@kevinwalldmd.com

Records Release Form for Requested Documents and X-Rays

*Name

*Email

*Phone Number

Date of Birth

Dental Practice Business Name

*Doctor

Doctor's Address

*Doctor's Phone Number

*Patients Signature

*Date

Forms

Medical History Form

Medical History

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Dr. Kevin S. Wall
340 Fairfield Avenue
Bellevue, KY 41073
Phone:859-291-7621
Fax: 859-0048
Email: admin@kevinwalldmd.com

Medical History

*Name

*Email

*Phone Number

*Physician Name

*Physician Phone Number

*Are You Under Any Medical Treatment Now?

Have You Ever Been Hospitalized For Any Surgical Operations or Serious Illness Within the Past 5 Years?

Yes

Please Explain

Are You Taking Any Medication(s) Including Non-Prescription Medicine

Yes

Please List

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

Anemia

Yes

Emphysema

Yes

Cancer

Yes

Arthritis

Yes

Joint Replacement

Yes

Hepatitis A, B, C or Jaundice

Yes

Please Check All That Apply

Jaundice

STD

Yes

Stomach Trouble / Ulcer

Yes

Chest Pains

Yes

Headaches / Migraines

Yes

Headaches, Migraines or Both?

Migraines

Headaches

Both

Stroke

Yes

Date of Stroke

Hay Fever / Allegies

Yes

Tuberculosis

Yes

Radiation / Chemotherapy

Yes

Glaucoma

Yes

Recent Weight Loss

Yes

Liver Disease

Yes

Fainting / Dizziness

Yes

Seizures

Yes

Epilepsy / Convulsions

Yes

Date of Last Episode

Asthma

Yes

High or Low Blood Pressure

Yes

High or Low?

High

Low

Both

Blood Transfusion

Yes

Leukemia

Yes

Sinus Problems

Yes

Diabetes

Yes

Type 1 or Type 2?

Type 1

Type 2

Kidney Disease

Yes

Disease / Dialysis or Both?

Disease

Dialysis

Both

Pneumonia

Yes

HIV / Aids

Yes

Thyroid Problems

Yes

Heart Disease

Yes

Cardiac Pacemaker

Yes

Heart Murmur

Yes

Angina

Yes

Date of Angina?

Aura Present?

Yes

Heart Attack

Yes

Date of Heart Attack?

Rheumatic Fever

Yes

Mitral Valve Prolapse

Yes

Snoring / Sleep Apnea

Yes

Acid Reflux / GERD

Yes

Parkinson's Disease

Yes

Problems Swallowing

Yes

Persistent CoughMore than 3 Weeks

Yes

Skin Graft

Yes

Please Explain Graft

Any Other Conditions

Yes

Please Explain Other Conditions

Are You Allergic or Have You Had Any Reaction to the Following?

Local Anesthetic

Yes

Penicillin

Yes

Amoxicillin

Yes

Erythromycin

Yes

Sulfa Drugs

Yes

Barbiturates

Yes

Sedatives

Yes

Iodine

Yes

Aspirin

Yes

Any MetalsNickel, Mercury, Silver, etc.

Yes

Latex Rubber

Yes

Other

Yes

Please Explain Other Allergies

For Women Only

Are You Pregnant or Think You May Be?

Yes

How Many Weeks?

Are You Nursing?

Yes

Taking Oral Contraceptives?

Yes

Are You On Hormone Replacement Therapy?

Yes

Are You Taking Calcium Replacement Medications?

Yes

Dental History

Name of Previous Dentist

Phone of Previous Dentist

Date of Last Exam

Date of Last X-Rays

Do Your Gums Bleed When Brushing or Flossing?

Yes

Are Your Teeth Sensitive to Hot / Cold / Sweets?

Yes

Sensitivities

Hot

Cold

Sweets

Do You Feel Pain in Any of Your Teeth?

Yes

Do You Have Any Sores / Lumps in or Near Your Mouth?

Yes

Any Head, Neck or Jaw Injuries?

Yes

Do You have Clicking, Popping, Pain or Trouble when Opening, Chewing or Closing Your Jaw?

Yes

Have You Had Orthodontic Treatment?

Yes

When?

Do You Use Tobacco Products?

Yes

Do You Clench or Grind Your Teeth?

Yes

Do You Have a Denture / Partial / Implant / Bridges?

Yes

Customer Testimonials

Dr. Wall is the best! The receptionist and dental hygienist are top notch! They are all friendly, professional and make your visit easy. Cleaning my teeth was painless and thorough. I live over 40 miles away but happily travel it every 6 months. Thank you Bellevue Family Denistry!

Janet Fay

From their awesome Meredith who schedules everything and deals with insurance to their friendly and sharp hygienists, Bellevue Family Dentistry is always a great experience. Dr. Wall is an expert who is gifted at his profession and as friendly as you’ll ever find.

Steve Oldfield

Excellent customer service the entire staff is polite courteous and professional always on time and a very friendly atmosphere.

Jane Hasenstab

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