Christopher D. Kooning DMD, PC
(503) 673-9097

New Patient Forms
Patient Information

Today's Date: ____/____/____

Mr. Mrs. Ms. Dr. Patient is: Policy Holder / Responsible Party / Both

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First Name Middle Name Last Name

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Address

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City State Zip

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Home Phone Work Phone/Ext Email

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Birth Date (MM/DD/YY) Social Security No. Drivers License #

Sex: Male / Female

Marital Status: Married Single Divorced Separated Widowed

When best to reach you? Time: ______ Email Text Phone Other

How did you find out about our clinic? Insurance, Internet, Referral______________________

Responsible Party: (If other than patient)

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First Name Middle Name Last Name

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Address

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City State Zip

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Home Phone Work Phone/Ext Cellular phone number

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Birth Date (MM/DD/YY) Social Security No. Drivers License State & No.


Insurance Information

Primary Insurance:

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Name Group No. Member ID

Name of Insured:_________________________________________________________________

Patient Relationship to Insured: Self Spouse/Partner Child Other

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Insured Social Security No. Insured Birth Date (MM/DD/YY)

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Employer of Insured Phone

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Address City State Zip



Secondary Insurance:

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Name Group No. Member ID

Name of Insured:__________________________________________________________________

Patient Relationship to Insured: Self Spouse/Partner Child Other

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Insured Social Security No. Insured Birth Date (MM/DD/YY)


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Employer of Insured Phone







Dental Assessment

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Patient Name Birth Date (MM/DD/YY)

What are your current dental needs? _____________________________________________

Do you have another dentist? Yes/ No

Dentist Name: ________________________________ Date of Last Visit: ____/____/________

Your current dental health? Good Fair Poor

Are you currently in pain? Yes / No

Do you require antibiotics before dental treatment? Yes / No

Do you floss daily? Yes / No

Brush daily? Yes / No

Do your gums ever bleed? Yes / No

Have you ever had periodontal disease? Yes / No

Are your teeth sensitive to heat, cold, or anything else? Yes / No

Do you have mobility in your teeth? Yes / No

Do you have wisdom teeth? Yes / No

Would you like whiter teeth? Yes / No

Are you happy with the way your smile looks? Yes / No

If not, what would you change? ________________________________________________________________________

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Office & Financial Policies

Treatment Policy
Welcome to our office. Dr. Kooning and team are committed to providing you with the best care possible in a comfortable environment. Dr. Kooning will recommend treatment that is individualized to your care and needs. He will offer options that are available to you based on the high standard of care. Our patient coordinator will review your options with you. Dr. Kooning will answer any questions and concerns. Our goal is for you to make an informed decision on what is best for you and your dental health.

Financial Policy
If you have dental insurance, we will gladly answer questions relating to your insurance and help you receive your maximum allowable benefits. Proposed treatment will be reviewed with you with an estimate of insurance percentage of payment and your expected payments per appointment. Payment in full on your portion will be expected when services are rendered. For all laboratory involved services, such as crowns and bridges, we will require full payment prior to beginning of treatment. Balances for services are considered the patient's responsibility. If your insurance company has not paid in full within 40 days of treatment, the balance will be expected from you. Your estimated insurance balance is not a guarantee of payment.

If you do not have dental insurance, full payment is due at time of service.

We accept cash, Visa, MasterCard, American Express, Care Credit, healthcare savings accounts and debit cards. Returned checks will be charged a $40 fee. A monthly statement will be sent to you regarding your account. Please call us at 503-675-4594 if you have any questions concerning your statement.

Appointment Policy
Your appointment time has been reserved specifically to meet your dental needs. Therefore, if you are unable to keep your appointment, we need 48 hours notice to schedule another patient. Failure to notify us within 48 hour, or to show for your appointment, may result in a $50.00 fee. If you arrive more than 10 minutes late for an appointment, we may opt to reschedule the appointment due to lack of adequate time for completion of the procedure. Minor children under the age of 10 must be accompanied by the child's parent or legal guardian for all appointments. The minor may be left alone only if the parent or guardian has given permission and will be accessible by phone and all treatment forms have been signed by parent or legal guardian. Thank you for choosing Dr. Kooning for you dental treatment.

I acknowledge that I am financially responsible for all charges incurred and I assign any insurance payments to be paid directly to Dr. Christopher Kooning DMD. I also authorize the release of any information including diagnosis and treatment records to my insurance company.


Signature: ____________________________________ Date: ____/____/____

Print Name: _________________________________________________________________



Notice of HIPPA Privacy Practice


This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our commitment here at Dr. Christopher Kooning DMD, PC Office is to serve our patients with professionalism at all times to protect the privacy and security of all Protected Health Information. During the course of serving your interest it may be necessary to share information with other Health Care Providers or Business Associates. The following are examples of Instances where information may be shared:

● during treatment, we may find it necessary to acquire a laboratory’s assistance
● during health care operations, we may need a second opinion
● during pending insurance claims, your insurance company may ask to see a copy of an x-ray or other treatment documentation

Dr. Christopher Kooning DMD, PC and Staff are committed to obeying all Federal, State and local laws and regulations regarding Privacy practices. If any other uses or disclosures than the one listed above are needed, information will only be released with the written authorization of the individual in question. The written authorization may be revoked anytime by the individual, as provided for by law.

● I authorize the doctor to initiate a complaint to the insurance commissioner for any reason on my behalf.
● I authorize Dr. Christopher Kooning DMD, PC to transfer records when necessary on my behalf.

Please list any person we may discuss your dental treatment or billing questions with: _____________________ Relationship: ____________________

If you have any questions or comments regarding your protected health information, feel free to call our office at 503-675-4594.

I have read and understand the above notice of privacy practice.

Signature: ___________________________________ Date: ____/____/____

Print Name: __________________________________________________________________
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Christopher D. Kooning DMD, PC
(503) 673-9097


Location
15962 Boones Ferry Rd, Suite 105
Lake Oswego, OR 97035


Hours
Monday:
Tuesday:
Wednesday:
Thursday:
Friday–Sunday:
8 AM–5 PM
8 AM–5 PM
8 AM–5 PM
8 AM–5 PM
Closed
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