Patient Form

Patient Form

Primary Dental Insurance

Secondary Dental Insurance

Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs.

Aids/HIV Positive
Hepatitis A
Renal Dialysis
High Blood Pressure
Epilepsy or Seizures
High Cholesterol
Excessive Bleeding
Sickle Cell Disease
Sinus Trouble
Blood Disease
Stomach/Intestinal Disease
Bruise Easily
Hay Fever
Chest Pains
Heart Attack/Failure
Cold Sores/Fever Blisters
Heart Murmer
Heart Pacemaker
Psychiatric Care
Veneral Disease
Radiation Treatments
Alzheimer's Disease
Drug Addiction
Hepatitis B or C
Rheumatic Fever
Scarlet Fever
Artificial heart Valve
Artificial Joint
Fainting Spells/Dizziness
Irregular Heartbeat
Kidney Problems
Blood Transfusion
Breathing Problems
Liver Disease
Low Blood Pressure
Swelling of Limbs
Lung Disease
Thyroid Disease
Mitral Valve Prolapse
Tumors or Growths
congenital Heart Disorder
Heart Trouble/Disease
Anxiety Disorder
I certify that I have read and understand and to the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to me or my child during the period of such dental care to a third party payers and/or health practitioners. I authorize that my insurance company to pay directly to the dentist/dental group, insurance benefits otherwise payble to me. I understand that my insurance carrier may pay less than the actual billed services. I agree to be responsible for all payments for all services rendered on my behalf or my dependents.
It is important to us that you, our patient, understand the treatment we are recommending and any invasive procedures we may, with your agreement, perform. We want to involve you in all decisions concerning invasive procedures you may need. We take informed consent very seriously in our office. Therefore, we only want you to sign this form when you understand that there is a risk associated with dental procedures, and all your questions have been answered.
Dental treatment and procedures are not to be taken for granted as being routine or without risk for complications. As with all medical treatment to one's body, including dental treatment, there are no guarantees that the results will be as planned and to each individual's satisfaction. When dealing with the human body there are potentially many variables, some predictable and others are not. Complication rates in dentistry are low but do exist. Even a minor procedure like "filling" can lead to major complications that cannot be foreseen. For example, "Novacaine" injection could lead to allergic reaction, anaphylaxis, facial hemorrhage, swelling, bruising, and even hospitilization or death. Granted these are fairy uncommon occurrences but individuals who are contemplating this should be aware of this prior to consenting. Whenever drilling is invloved, even a simple cavity can lead to pulpal (nerve) problems, abscess, fractured tooth, and/or post treatment pain to biting and to temperature extremes (hot and cold). These complaints can be transient or may persit requiring further treatments. The above examples are only samples of possible complications with dental treatment and are not limited to these. In general, complications include but are not limited to pain, swelling, bleeding, infection, and other nerve problems.

I have read, understand and consent to dental treatments.

I have received this practice's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. I understand I can obtain this practice's current Notice of Privacy Practices on request.
Patients without insurance coverage are required to pay for services as rendered, We accept cash, Visa, MasterCard, American Express and Discover or Debit/ATM cards. We offer an in-house customized Membership Plan. We offer 5% courtesy on the prepayment of Patient-Doctor discussed treatment plans. We offer up to 12 months interest free financing plans.
When you make an appointment we reserve that time for you. We undrestand that extreme or unavoidable emergencies or circumstances do arise which may require you to cancel your appointment. We reserve the right to charge for any appointment(s) broken without a 48 hours notice. The charge will be $50.00 for every thirty minutes of appointment time. Checks returned from the bank is subject to $ 35.00 service fee.
Account delinquent more than 60 days form the date of billing are subject to a 1.5% per month (18% annually) finance charge. If your account is sent to our collection agency you will be responsible for collection and court costs along with attorney's fees.
We welcome you to our office and want to provide you with the best dental care possible. If you have any questions regarding our policies and your treatment, please do not hesitate to ask.
Thank you for choosing us as your dental care provider. We are committed to your dental treatment being successful. We agree in writing with every patient to sign our financial policy, as we have found with our past experience that this policy makes our mutual experience easier and without confusion. This policy is to ensure that all of our patients receive a highest level of quality dental care in a friendly and healthy environment while understanding their financial responsibilities. This policy as well as other health and insurance forms provided must be read, agreed to, and signed prior to any dental treatment.
Patients with no insurance are expected to pay in cash, check or credit card the day the service is rendered, unless specific arrangements are made in advacne.
For those patients covered by insurance, we may accept assignment of benefits. This means you must sign the portion of your insurance form that assigns payment to our office. Very few insurance policies cover 100% of the cost of your treatment. In this day and age many cover 50% or less on many services and actually cover nothing on others. Due to this, and the frequent delays in receiving payment from the insurance company, you will be asked to pay your deductible and your portion of your charges the day the service is rendered. We will estimate as closely as possible, your coverage, but until we actually receive the payment from the insurance company, it is just an estimate. Some patients request that we send in a pre-determination to their insurance carriers. We state what treatment you need, and they tell us what they will cover on that treatment plan. Many patients prefer to get service started immediately, and some treatments should be started immediately. In these cases we will ask you to pay for your services in full as they are done, and when the insurance company pays their portion we will reimburse you for what they pay. We will assist you in dealing with the insurance company, but ultimately the responsibility of payment and insurance problems lies with you. If we do accept assignment of benefits from the insurance company, if the insurance company hasn't paid after 45 days, the full balance is expected from you personally.
The above policies apply equally to parents and guardians of minors being treated, and minors cannot be treated without a parent or guardian authorizing treatment and agreeing to financial responsibility. Thank you for reading and understanding our financial policy. If you have any questions or concerns: please feel free to ask them at any time. We wish to be of assistance in any way we can.
Our Dental Team

I have read and understand the above dental office informed financial policies.

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