Patient Information mConsent Online Form Login

Address:

Gender

Male Female

Marital Status

Minor Single Divorced Married Widowed

Phone Number:

Full Time Part Time

Are any of your family members our patients?

Yes No

If Yes, Who?

How did you hear about us(Please Be Specific)?

Previous Dentist's Name:

Previous Dentist's Phone No.

Last Dental Visit Date:

Primary Dental Insurance

Name of Insurance Co:

Phone No

Subscriber's Name:

Date of birth

Relationship

Employer's Name:

Group No

SS No/ID No

Secondary Dental Insurance

Name of Insurance Co:

Phone No

Subscriber's Name:

Date of birth

Relationship

Employer's Name:

Group No

SS No/ID No

Health History

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.

Physician's Name:

Phone No:

Are you having any pain or discomfort at this time?

Yes No

Have you ever had a full mouth x-rays taken of your teeth? if yes, when?

Yes No

Have you ever had treatments for your gums?

Yes No

Do your gums hurt or bleed when you brush?

Yes No

Do your teeth hurt when you chew?

Yes No

Have you ever had orthodontic treatment or worn braces?

Yes No

Have you ever been aware of a bad odor or taste in your mouth?

Yes No

Are your teeth sensitive to hot, cold or sweet?

Yes No

Do you clench or grind your teeth during day or night?

Yes No

Do you ever wake up from sleep due to shortness of breath

Yes No

Are you on a special diet?

Yes No

Do you use a tobacoo products? What and how much

Yes No

Do you use alcoholic beverages?

Yes No

How much

How often

Have you been a patient in the hospital during past two years? For what

Yes No

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking

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 head or neck injury?

Yes No

If Yes

Are you taking any medications, pills, or drugs?

Yes No

If Yes

Do you use tobaco?

Yes No

Are you allergic to any or have you reacted adversely to any of the following

Aspirin Pencilin Codene Acrylic

Metal Latex Sulfa Drugs Local Anesthetics

Davon Demerol Scopolamine Nitrous Oxide

Valium Erythromycin Percocet Sleeping Pills

Ibuprofen Vicodin Cortisone Epinephrine

Do you have, or have you had, any of the following?

Aids/HIV Positive

Yes No

Hemophilia

Yes No

Diabetes

Yes No

Hepatitis A

Yes No

Renal Dialysis

Yes No

Anemia

Yes No

Emphysema

Yes No

High Blood Pressure

Yes No

Epilepsy or Seizures

Yes No

High Cholesterol

Yes No

Excessive Bleeding

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Asthma

Yes No

Sinus Trouble

Yes No

Blood Disease

Yes No

Leukemia

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Glaucoma

Yes No

Chemotherapy

Yes No

Hay Fever

Yes No

Chest Pains

Yes No

Heart Attack/Failure

Yes No

Cold Sores/Fever Blisters

Yes No

Heart Murmer

Yes No

Heart Pacemaker

Yes No

Ulcers

Yes No

Psychiatric Care

Yes No

Veneral Disease

Yes No

Radiation Treatments

Yes No

Alzheimer's Disease

Yes No

Drug Addiction

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Arthritis/Gout

Yes No

Scarlet Fever

Yes No

Artificial heart Valve

Yes No

Artificial Joint

Yes No

Hypoglycemia

Yes No

Fainting Spells/Dizziness

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Blood Transfusion

Yes No

Breathing Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Swelling of Limbs

Yes No

Lung Disease

Yes No

Thyroid Disease

Yes No

Mitral Valve Prolapse

Yes No

Tronsillitis

Yes No

Osteoporosis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

congenital Heart Disorder

Yes No

Convulsions

Yes No

Heart Trouble/Disease

Yes No

Pacemaker

Yes No

Anxiety Disorder

Yes No

Have you ever had any serious illness not listed above?

Yes No

If Yes

Women: Are you

Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?

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.

Initials:

Dental Office Informed Consent

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.

Initials:

Notice of privacy practices patient acknowledgement

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.

Signature:

Relationship to patient (if signed by a personal representative of patient):

Patients without insurance coverage

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.

Office Policy

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.

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

Our Financial Policy

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.

Cash Patients

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.

Insurance Patients

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.

Sincerely,

Our Dental Team

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

Signature of responsible party:

Date:

Please print your name: