New Patient Information « University Dental Group

New Patient Information

For a typical new patient exam dental x-rays are taken and reviewed, a complete exam including oral cancer screening, cavity detection, and periodontal screening is done. Most patients have a thorough cleaning at their first visit and any further treatment recommendations are reviewed by the dentist.

You can schedule your first visit by phone at (407) 679-5151 or click the “Schedule appointment” button to email our reception desk with your preferred date and time.

Fill out your medical history here, before or after submitting the form below.

We will never share your information with a third party or share your personal information with anyone.

Patient's Name: Nick Name: Cell Phone: Referral: Date of Last Visit: Purpose of Last Visit:

Responsible Party for Patient:

Name and Address: Social Sec. Num.*: Employer: Business Address/City/Zip: Name and Phone of Nearest Relative (Not Living With You):

* Entering your social security number is not mandatory at this time.

How did you hear about us?

Another Patient Staff Member Local Physician or Doctor Location/Sign Search Engine YellowPages YP.com Website Other

Acklowledgement of receipt for notice of privacy practices:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for University Dental Group, P.L. A copy of this signed, dated Acknowledgement shall be as effective as the original.

I have read the seperate document with the full disclosure agreement here Patient Name: SIGN NAME (Re-type Name):

Consent for treatment:

The undersigned hereby authorizes the doctor to make x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated for the above named patient after being informed of the treatment recommended by the doctor. I further authorize the doctor to choose and employ such assistance as he deems fit. I also understand that the use of anesthetic agents embodies a certain risk. I understand that the responsibility for payment for all dental services provided in this office for my dependents and me is mine, due and payable at the time services are rendered, and that insurance is not accepted in lieu of payment. I also understand that all x-rays and diagnostic aids are the property of University Dental Group, P.L. and that copies, if requested, will be made available to me for a reasonable fee as set by this office. I authorize the release of any payment and dental information necessary to process claims on my behalf. I understand that Missed Appointments and Appointments Cancelled with less than 24 hours notice will be charged a $50.00 fee.

SIGN NAME (Re-type Name): Date (MM/DD/YYYY):

Office Location

University Dental Group, P.L.
4051 North Dean Road
Suncrest Shopping Village
Orlando, FL 32817
Phone: 407-679-5151
Hours: Monday - Friday
8:00 am - 5:30 pm