Skip to main content
Hit enter to search or ESC to close
Close Search
Menu
Home
Our Team
Our Services
The Difference
Patient Reviews
Appointment
Book an Appointment
New Patient Form
Please complete the below form.
We will get back with you shortly after it’s complete.
Thank You!!
Step
1
of
5
20%
Patient Information
Name
*
First
Middle
Last
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Today's Date
*
MM slash DD slash YYYY
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Marital Status
*
Single
Married
Home Phone
*
Cell Phone
*
Whom may we thank for referring you to our practice?
Responsible Party Information
Who is responsible for payment?
*
Self
Spouse
Parent / Guardian
Chose One
Name of Responsible Party
First
Last
Responsible Party Social Security Number:
*
Responsible Party Driver's License Number
*
State Drivers License was Issued
*
Home Phone
Work Phone
*
Cell Phone
Email
*
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Insurance Information
Relationship to the Policy Holder
Self
Spouse
Child
Other (Specify)
Specify Relationship
Employer
Employer's Address
Name of Dental Insurance Company
Dental Insurance Phone:
ID #
Group Name:
Group #:
Policy Holder's Name
First
Last
Policy Holders Date of Birth
MM slash DD slash YYYY
Policy Holders Social Security Number
Home Phone
Work Phone
Cell Phone
Medical Information
Are you under a physician's care now?
*
Yes
No
If yes:
Have you ever been hospitalized or had a major operation?
*
Yes
No
If yes:
Have you ever had a serious neck or head injury?
*
Yes
No
If yes:
Are you taking any medication, pills or drugs?
*
Yes
No
If yes:
Do you take, or have you taken, Phen-Fen or Redux?
*
Yes
No
If yes:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
*
Yes
No
If yes:
Are you on a special diet?
*
Yes
No
If yes:
Do you use tobacco?
*
Yes
No
If yes:
Do you use controlled substances?
*
Yes
No
If yes:
Women; Are you...
Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
Are you allergic to any of the following?
*
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetic
Other
None of the above
If other please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
*
Yes
No
Alzheimer's Disease
*
Yes
No
Anaphylaxis
*
Yes
No
Anemia
*
Yes
No
Angina
*
Yes
No
Arthritis/Gout
*
Yes
No
Artificial HeartValve
*
Yes
No
Artificial Joint
*
Yes
No
Asthma
*
Yes
No
Blood Disease
*
Yes
No
Blood Transfusion
*
Yes
No
Breathing Problems
*
Yes
No
Bruise Easily
*
Yes
No
Cancer
*
Yes
No
Chemotherapy
*
Yes
No
Chest Pains
*
Yes
No
Cold Sores/Fever Blisters
*
Yes
No
Congenital Heart Disorder
*
Yes
No
Convulsions
*
Yes
No
Cortisone Medicine
*
Yes
No
Diabetes
*
Yes
No
Drug Addiction
*
Yes
No
Easily Winded
*
Yes
No
Emphysema
*
Yes
No
Epilepsy or Seizures
*
Yes
No
Excessive Bleeding
*
Yes
No
Excessive Thirst
*
Yes
No
Fainting Spells/Diaziness
*
Yes
No
Frequent Cough
*
Yes
No
Frequent Diarrhea
*
Yes
No
Frequent Headaches
*
Yes
No
Genital Herpes
*
Yes
No
Glaucoma
*
Yes
No
Hay Fever
*
Yes
No
HeartAttack/Failure
*
Yes
No
Heart Murmur
*
Yes
No
Heart Pacemaker
*
Yes
No
Hemophilia
*
Yes
No
Hepatitis A
*
Yes
No
Hepatitis B or C
*
Yes
No
Herpes
*
Yes
No
High Blood Pressure
*
Yes
No
High Cholesterol
*
Yes
No
Hives or Rash
*
Yes
No
Hypoglycemia
*
Yes
No
Irregular Heartbeat
*
Yes
No
Kidney Problems
*
Yes
No
Leukemia
*
Yes
No
Liver Disease
*
Yes
No
Low Blood Pressure
*
Yes
No
Lung Disease
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Osteoporosis
*
Yes
No
Pain in Jaw Joints
*
Yes
No
Parathyroid Disease
*
Yes
No
Psychiatric Care
*
Yes
No
Radiation Treatments
*
Yes
No
Recent Weightloss
*
Yes
No
Renal Dialysis
*
Yes
No
Rheumatic Fever
*
Yes
No
Rheumatism
*
Yes
No
Scarlet Fever
*
Yes
No
Shingles
*
Yes
No
Sickle Cell Disease
*
Yes
No
Sinus Trouble
*
Yes
No
Spina Bifida
*
Yes
No
Stomach/Intestinal Disease
*
Yes
No
Stroke
*
Yes
No
Swelling of limbs
*
Yes
No
Thyroid Disease
*
Yes
No
Tonsillitis
*
Yes
No
Tuberculosis
*
Yes
No
Tumors or Growths Ulcers
*
Yes
No
Venereal Disease
*
Yes
No
Yellow Jaundice
*
Yes
No
Have you ever had any serious illness not listed above?
*
Yes
No
If yes:
Comments
Appointment Policy
*
I agree to the appointment policy.
We understand that your time is valuable, and we always try to accommodate your schedule for appointments. This makes our time very valuable as well. We also make every effort to remind you of your scheduled appointment time by using the communication means you have given us. In order to avoid broken appointments and late patient arrivals, the following policy has been adopted:
-All cancellations or rescheduled appointments must be arranged 48 hours prior to appointment date.
-If your appointment is on Monday please remember we are closed on Fridays and need to hear from you by Thursday at 3:00pm.
-Patients arriving more than 10 minutes late may be rescheduled.
-Patients who do not give adequate notice to reschedule or do not show up will be charged $75.00
ACKNOWLEDGEMENT AND AUTHORITY
*
I agree.
I consent to treatment as necessary or desirable to my care, including but not restricted to whatever drugs, medicine, performance of operations and conduct of laboratory, x-ray, or other studies that may be used by the attending doctor, or his assistant or qualified designate.
I consent to the office submitting my claim to my insurance company and to the assignment of benefits. I understand the dental office will allow 60 days for my claim to be paid, after which, interest will be charged to my account.
I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, AT THE TIME OF SERVICE, unless other arrangements are made with the financial department. I acknowledge that should I default on the financial obligation, the dental office shall be entitled to recover all reasonable collection cost, attorney fees, and court cost accrued in collection of the debt. I further acknowledge that the dental office shall be entitled to change interest on my balance past due at the current rate.
HEALTH HISTORY
*
I agree.
I have reviewed my health history with the attending doctor, his assistant, or qualified designate. IfI required changes be made to my health history, they were made in the computer system.
Notice of Privacy Practices
*
I have read the Notice Of Privacy Practices and understand my rights regarding my confidential information.
Under Idaho law, Hillary Whipple D.M.D. may use or disclose your personal health information to a family member, friend, or other person involved in your health care if you are present and you do not object or in the event of an emergency; to comply with applicable federal, state or local laws; for public health reasons such as to control diseases; to report a suspected case of abuse, neglect or domestic violence; to comply with health oversight activities related to health care services; to the U.S. Department of Health and Human Services; to law enforcement officials for a law enforcement purpose; to respond to legal process; for purposes of public safety or national security; to allow a funeral director to carry out his or her duties; to allow a coroner or medical examiner to identify you or determine cause of death; or to respond to a request by military command authorities.
YOUR RIGHTS ABOUT YOUR CONFIDENTIAL INFORMATION
Right to review and copy: You have the right to review and copy your information as allowed by law. There may be a fee for copying your records.
Right to amend: You have the right to ask us to make changes to your information if you feel that the information we have about you is wrong or not complete. We may deny your request if you ask us to change information that: a) Was not created by Dr. Hillary Whipple, b) Is not part of the information which you would be allowed to review and copy, c) We determine it to be correct and complete.
Right to restrict health information disclosure: You have the right to ask us not to share your health information for your treatment or services, or normal business purposes. You must tell us what information you do not want us to share and who we should not share it with. If we agree to your request, we will comply unless the information is needed to give you emergency treatment, or until you end the restriction.
Right to an alternate means of delivery: You have the right to ask that we deliver your information to you at a different mailing address.
Close Menu
Home
Our Team
Our Services
The Difference
Patient Reviews
Appointment
Book an Appointment
New Patient Form