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(206) 225-2882
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(425) 337-2400
Seattle Office
(206) 225-2882
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(425) 337-2400
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About Periodontics
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Invisalign Teen
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Icon Dental Center – Everett Location
Seattle Dental Office
Pay Online
Menu
Home
About Us
Meet Dr. Aboulhosn
Meet Dr. Valentine
Meet Our Specialists
Meet Our Team
Advanced Technology
Blog
Write Us A Review
New Patients
Why Choose Us
First Visit
Financing & Insurance
CareCredit
Testimonials
Smile Gallery
New Patient Form
General Dentistry
Routine Exams & Cleanings
Tooth Extractions
Dental Fillings
Sedation Dentistry
Children’s Dentistry
Emergencies & Walk-Ins
Periodontics
About Periodontics
Crown Lengthening
Dental Implants
Bone Grafts
Periodontal Surgery
Smile Restoration
Teeth Whitening – Seattle & Everett Dental Office Locations
Dentures
Dental Bridges
Dental Crowns
Dental Veneers
Inlays & Onlays
Orthodontics
Braces
Invisalign Info
Invisalign Teen
Cost of Invisalign
Contact Us
Icon Dental Center – Everett Location
Seattle Dental Office
Pay Online
New Patient Registration Form
New-Patient-Registration
PATIENT INFORMATION
Hidden
Name
*
First
Last
Preferred Name
Date of Birth
MM slash DD slash YYYY
Age
Sex
Male
Female
Social security number
*
Mailing Address
Street Address
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
Home phone
Mobile phone
Other
Hidden
Email
*
Our office uses an electronic reminder system. How would you like to receive your reminder?
Text Message
Email
Phone call
How did you hear about our office?
EMERGENCY CONTACT
Name
First
Last
Phone Number
Relationship to patient
DENTAL INSURANCE
Policy holder Name
Date of Birth
MM slash DD slash YYYY
Social security number
*
Identification Number
Group Number
Employer
SECONDARY INSURANCE (if applicable)
Policy holder Name
Date of Birth
MM slash DD slash YYYY
Social security number
*
Identification Number
Group Number
Employer
DENTAL HISTORY
What is the reason for your visit today?
Are you apprehensive about dental treatment?
Have you had problems with previous dental treatment
Please Select
Yes
No
If yes please describe
Are you interested in:
Whitening your teeth
Braces/Invisalign
Cosmetic treatment
DENTAL HISTORY
Previous Dentist
Phone number
When was your dental exam/cleaning?
Do you have any immediate concerns/pain?
Please circle YES or NO if you have, or ever had the following:
Unhappy with appearance of your teeth
Yes
No
Burning sensation in the mouth
Yes
No
Unfavorable dental experience/fear
Yes
No
Difficulty swallowing
Yes
No
Preference for no dental anesthetic
Yes
No
Unpleasant taste or odor in your mouth
Yes
No
Difficulty/Reactions to dental anesthetic
Yes
No
Jaw problems/pain/clicking/locking
Yes
No
Orthodontic treatment/Braces
Yes
No
Difficulty opening wide
Yes
No
Periodontal (Gum) treatment
Yes
No
Stiff neck muscles
Yes
No
Bleeding Gums
Yes
No
Tension headaches
Yes
No
Bleeding Avoid brushing any parts of your mouth
Yes
No
Clench or grind your teeth
Yes
No
Sensitivity to temperature in the mouth
Yes
No
Sore teeth
Yes
No
ALLERGIES
ASPIRIN, ACETAMINOPHEN, or IBUPROFEN
PENICILLIN
OTHER ANTIBIOTICS
CODEINE/NARCOTICS
LATEX
FLUORIDE
LOCAL ANESTHESIA
METALS
SULFA
MEDICAL INFORMATION
Physician or Clinic name
Phone
Please circle YES or NO if you have, or ever had the following:
Anemia
Yes
No
Cough up blood
Yes
No
Narcolepsy
Yes
No
Angina
Yes
No
Diabetes
Yes
No
Kidney Disease
Yes
No
Anxiety
Yes
No
Epilepsy
Yes
No
Liver Disease
Yes
No
Arthritis
Yes
No
Fainting
Yes
No
Mitral Valve Prolapse
Yes
No
Artificial joint/heart valve
Yes
No
Fatigue
Yes
No
Pacemaker
Yes
No
Asthma
Yes
No
GERD
Yes
No
Radiation therapy
Yes
No
Acid Reflux
Yes
No
Headaches
Yes
No
Respiratory Disease
Yes
No
Back problems
Yes
No
Heart attack
Yes
No
Sleep Apnea
Yes
No
Blood disease
Yes
No
Heart Murmur
Yes
No
Stroke
Yes
No
Chemical dependency
Yes
No
Hemophilia
Yes
No
Thyroid Problems
Yes
No
Glaucoma
Yes
No
Hepatitis
Yes
No
Tuberculosis
Yes
No
Chemotherapy
Yes
No
High blood pressure
Yes
No
Ulcer
Yes
No
Cancer
Yes
No
HIV/AIDS
Yes
No
Depression
Yes
No
Have you had any serious type of illness or operation?
Yes
No
If Yes describe
If you have a disease, condition or problem not previously listed, please describe
Have you ever taken Fosamax, Boniva, Actonel, or any other cancer medications?
Yes
No
Do you use tobacco?
Yes
No
Has your Doctor ever told you that you require a Pre-Medication?
Yes
No
(Women) Are you currently pregnant or trying to?
Yes
No
Nursing?
Yes
No
Please list any/all medications you are currently taking;
Patient name (Printed)
Signature
DDS signature
Date
MM slash DD slash YYYY
FINANCIAL POLICY
Thank you for choosing Icon Dental Center as your dental health care provider. We are committed to providing the best dental care possible. Please understand that payment of your bill is considered a part of your treatment. The following statement explains our Financial Policy which we ask you to read, sign and return to us prior to your treatment.
Please provide accurate and complete personal and insurance information prior to being seen by the dentist.
All applicable co-pays, personal balances, both current and prior, are due at the time of service or upon receipt of invoice.
We accept Cash, Check, Visa, Master card, Discover, Care credit and Health savings account cards.
Regarding your Dental Insurance
We participate in most insurance plans, however we require that the guarantor, the person who is financially responsible, is personally liable for all balances not covered by insurance. It is your responsibility to understand your dental benefits. Please be aware that some and perhaps all of the services provided may be non-covered services or may not be considered dentally necessary under your dental insurance. Please understand that insurance is always an estimate and never guarantee of coverage. Final determination will be made when the claim is received and processed by your insurance. We will file all insurance claims with the insurance provider you supply our office with. Please be sure to update our office of any changes in your insurance. Please also remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. Your insurance company may need you to supply certain information directly in order to pay the claim. If you are uncertain about your current insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket expenses and, coverage limits.
Initials:
Cost of Treatment
Treatment plans are customized for your individual care. To that end we want you to be aware of your financial investment into your care and do so by providing estimates of your out-of-pocket expenses based upon your plan. Please understand that any estimate given is just an estimation of costs as there are many factors that contribute to the treatment and insurance coverage.
Initials:
Missed appointments
To provide the best care possible for each patient, Icon dental center requires a 48 hours business day notice for any cancelations or changes, to avoid a charge. Appointments that are missed or canceled without notice will be assessed with a $100.00 per hour scheduled, fee.
Initials:
Minors
The parent(s), guardian(s), or Financial Guarantors is responsible for full payment and will receive the billing statements. A signed release to treat may be required for unaccompanied minors.
Initials:
Past Due Accounts
I/We agree to pay all attorney’s fees, court costs, and filing fees, which may be assessed by any collection agency or law firm retained to pursue the matter. Additionally, past due balances shall accrue interest at the rate of twelve (12%) percent per annum.
Initials:
Address Changes
It is our policy to provide invoices for any amounts owed on your account. We send all correspondence to the address information you provide, so please advise us anytime there is a change to your address, telephone number or other contact information.
Returned Checks
For checks returned to us as unpaid by your bank, we will charge a $25.00 fee.
I authorize Icon Dental Center to release pertinent dental/medical information to my insurance company when requested, or to facilitate payment of a claim. I authorize my insurance benefits to be paid directly to Icon Dental Center.
I have read the Financial Policy. I understand and agree to the Financial Policy
Financial Guarantor- Printed Name
Signature
Date
MM slash DD slash YYYY
PRIVACY POLICY – ACKNOWLEDGEMENT OF RECEIPT
I certify that I have received a copy of Icon Dental Center Notice of Privacy Practice. The Notice of Privacy describes the types of uses and disclosures of my protested health information that might occur in my treatment, payment for services or in the performance of office’s health care operations. The Notice of Privacy Practices also describes my rights and Icon Dental Center’s duties with respect to my protected health information. The Notice of Privacy Practices is posted in the facility.
Icon Dental Center reserves the right to change the privacy practices that are described in the Notice of Privacy ractices. If privacy practices change, I will be offered a copy of the revised Notice at the time of my first visit after the revisions become effective. I may also obtain a revised Notice by requesting that one be mailed to me.
ADDITIONAL DISCLOSURE AUTHORITY
I hereby specifically authorize disclosure of my protected health care information to the persons indicated below; this may include appointment information, insurance and sensitive personal information to;
Any member of my immediate family
Yes
No
Spouse Only
Yes
No
Other (Specify)
Yes
No
Patient name (Printed)
Signature
Date
MM slash DD slash YYYY
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Everett
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