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Dr. Chiu
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Patient Forms

Privacy Practices and Financial Policy
New Patient Information Form

Alternatively, you may complete the new patient form below.

1 Patient Information

2 Insurance Information

3 Phone Numbers

4 Dental History

5 Health History

6 Medications, Supplements, Remedies & Allergies

7 Physicians

Todays Date
Patient Name*
First Last
Status*
Preferred Name
Email
Birth Date*
Age
Sex*
- Male
- Female
SSN*
Cell Phone*
Work Phone
Home Phone
Best way to contact you for appointment reminders:*
- Email
- Text
Address*
Street Address Address Line 2 City State ZIP Code
Occupation
Employer
Employer's Phone
Employer's Address
Street Address Address Line 2 City State ZIP Code
Spouse's Name
First Last
Spouse's Birth Date
Spouse's SS#
Spouse's Phone Number
Spouse's Employer
Whom may we thank for referring you?

Who is the subscriber for your dental insurance?*
Subscriber's Name*
First Last
SS#
Relationship to Patient
Insurance Co*
ID #*
Group #
Birth Date*
Relationship to Patient
Insurance Co
Group #
Is patient covered by additional insurance?
- Yes
- No
Assignment and Release

I Certify that I, and/or my dependent(s), have insurance coverage with the following Insurance Company(ies) and assign directly to Cornerstone Dental all insurance benefits, of any, otherwise payable to me for services rendered. I Understand that I am financially responsible for all charges whetehr or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Name of Insurance Company(ies)
I give my permission to Cornorstone Dental and its affiliates to use and disclose my health care information to the Insurance Company (ies) I so designate and their agents for the purpose of determining insurance benfits, obtaining payment for services, or the benefits payable for related services.
Name of Patient, Parent, Guardian or Personal Representative
First Last
Date
Relationship to Patient
Signature*

Home Phone*
Work Phone
Extension
Cell Phone*
Spouse's Work Phone
Best time and place to reach you
In case of emergency, Contact

(Specify someone who does not live in your household)
Name*
First Last
Relationship*
Home Phone*
Work Phone

Reason for today's visit
Former Dentist
City / State
Date of last dental visit
Date of last dental X-rays
Place a mark on 'Yes' or "No' to indicate if you had any of the following:
Bad Breath*
- Yes
- No
Bleeding gums*
- Yes
- No
Blisters on lips or mouth*
- Yes
- No
Are you happy with your smile?*
- Yes
- No
Burning sensation on tongue*
- Yes
- No
Chew on one side of mouth*
- Yes
- No
Cigarette, pipe or cigar smoking*
- Yes
- No
clicking or popping jaw*
- Yes
- No
Dry mouth*
- Yes
- No
Fingernail biting*
- Yes
- No
Food collection between the teeth*
- Yes
- No
Foreign objects*
- Yes
- No
Grinding teeth*
- Yes
- No
Gums swollen or tender*
- Yes
- No
Jaw pain or tiredness*
- Yes
- No
Lip or cheek biting*
- Yes
- No
Loose teeth or broken fillings*
- Yes
- No
Mouth breathing*
- Yes
- No
Mouth pain, brushing*
- Yes
- No
Orthodontic treatment*
- Yes
- No
Pain around ear*
- Yes
- No
Periodontal treatment*
- Yes
- No
Sensitivity to cold*
- Yes
- No
Sensitivity to heat*
- Yes
- No
Sensitivity to sweets*
- Yes
- No
Sensitivity when biting*
- Yes
- No
Sores or growths in your mouth*
- Yes
- No
How often do you floss?*
How often do you brush?*
Do you have any dental concerns you would like to discuss?*
- Yes
- No

Primary Care Physician's Name
Primary Care Physician's Phone Number
Date of last visit
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)
- Yes
- No
Place a mark on 'Yes' or "No' to indicate if you had any of the following:
AIDS / HIV*
- Yes
- No
Anemia*
- Yes
- No
Arthritis, Rheumatism*
- Yes
- No
Artificial Heart Valves*
- Yes
- No
Artificial Joints*
- Yes
- No
Asthma*
- Yes
- No
Back Problems*
- Yes
- No
Bleeding abnormally, with extractions or surgery*
- Yes
- No
Blood Disease*
- Yes
- No
Cancer*
- Yes
- No
Chemical Dependency*
- Yes
- No
Chemotheraphy*
- Yes
- No
Circulatory Problems*
- Yes
- No
Congenial heart Lesions*
- Yes
- No
Cortisone treatments*
- Yes
- No
Cough, persistent or bloody*
- Yes
- No
Diabetes*
- Yes
- No
Emphysema*
- Yes
- No
Epilepsy*
- Yes
- No
Fainting or dizziness*
- Yes
- No
Glaucoma*
- Yes
- No
Headaches*
- Yes
- No
Heart Murmur*
- Yes
- No
Heart Problems*
- Yes
- No
Hepatitis*
- Yes
- No
Hepatitis Type*
Herpes*
- Yes
- No
High blood pressure*
- Yes
- No
Jaundice*
- Yes
- No
Jaw pain*
- Yes
- No
Kidney Disease*
- Yes
- No
Liver Disease*
- Yes
- No
Low blood pressure*
- Yes
- No
Mitral valve prolapse*
- Yes
- No
Nervous problems*
- Yes
- No
Pacemaker*
- Yes
- No
Psychiatric care*
- Yes
- No
Radiation treatment*
- Yes
- No
Respiratory Disease*
- Yes
- No
Rheumatic fever*
- Yes
- No
Scarlet fever*
- Yes
- No
Shortness of breath*
- Yes
- No
Sinus trouble*
- Yes
- No
Skin Rash*
- Yes
- No
Special Diet*
- Yes
- No
Stroke*
- Yes
- No
Swollen feet or Ankles*
- Yes
- No
Swollen neck glands*
- Yes
- No
Thyroid problems*
- Yes
- No
Tonsilitis*
- Yes
- No
Tuberculosis*
- Yes
- No
Tumor or growth on head or neck*
- Yes
- No
Ulcer*
- Yes
- No
Venereal disease*
- Yes
- No
Weight loss, unexplained*
- Yes
- No
Have you ever been told you need to take pre-medication before a dental procedure?*
- Yes
- No
Do you wear contact lenses?*
- Yes
- No
Women
Are you pregnant?*
- Yes
- No
Due Date
Are you nursing?*
- Yes
- No
Taking birth control pills?*
- Yes
- No

Are you currently taking any medications?*
- Yes
- No
Please list any medications, supplements or homeopathic remedies you are currently taking and the correlating diagnosis. If none, please type "none."*
Pharmacy Name
Phone
Allergies
Allergies*
- Aspirin
- Barbiturate (Sleeping pills)
- Codeine
- Iodine
- Latex
- Local Anesthetic
- Penicillin
- Sulfa
- Other
- None
Other

Please list names, location and phone numbers of all your attending doctors.
1st Dr Name
Location
Phone
2nd Doctor Name
Location
Phone
Please list any surgeries or medical conditions you have or have ever had.
- We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly mutual understanding between provider and patient.
- Our policy requires payment in full at the time services are rendered, unless other formal written arrangements have been made with our office management. If the account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for all legal fees, collection agency fees, interest charges and any other expenses incurred for collection of the debt.
- I authorize the staff of Cornerstone Dental to perform any necessary services needed during diagnosis and treatment.
- Filing of insurance claims is a courtesy we provide to our patients. I authorize Cornerstone Dental to release any information required to process my insurance claims.
- I understand the above information and state this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to this information I provided.
Print name of Patient, Parent, Guardian or Personal Representative*
First Last
Date*
Signature*

Welcome
Dr. Moon
Our Practice
Procedures
invisalign
Smile Analysis
Patient Forms
Faqs
Contact Us

Leesburg dentist, Sue Moon is a dental professional dedicated to general, family, and cosmetic dentistry with services including dental exams, cosmetic dentistry, gum disease treatment and more. Call Cornerstone Dental in Leesburg, VA for more details or to schedule an appointment.