PRINT
A COPY OF ME AND BRING FILLED OUT PRIOR TO YOUR APPOINTMENT
|
|
AIDS |
Heart Murmur |
Respiratory Problems |
|
Allergies_____________ |
Hepatitis |
Rheumatic Fever |
|
Anemia |
High Blood Pressure |
Rheumatism |
|
Arthritis |
Head Injuries |
Sinus Problems |
|
Artificial Joints |
Heart Disease |
Stomach Problems |
|
Asthma |
Hay Fever |
Stroke |
|
Blood Disease |
Jaundice |
Tuberculosis |
|
Cancer |
Kidney Disease |
Tumors |
|
Diabetes |
Liver Disease |
Ulcers |
|
Dizziness |
Mental Disorders |
Venereal Disease |
|
Epilepsy |
Nervous Disorders |
Latex Allergy |
|
Excessive Bleeding |
Pacemaker |
Codeine Allergy |
|
Fainting |
Pregnancy |
Penicillin Allergy |
|
Glaucoma |
Due date:_________ |
OTHER: |
|
Growths |
Radiation Treatment |
________________ |
·
Have you ever had any complications following dental treatment?
Yes No
If yes, please explain:
____________________________________________________________________________
·
Have
you been admitted to a hospital or needed emergency care during the
past two years?
Yes No
If yes, please explain:
____________________________________________________________________________
·
Are
you now under the care of a physician?
Yes No
If yes, please explain:
______________________________________Name of
Physician:_____________________
·
List
any medications: ____________________________________________________________________________
·
Do
you have any health problems that need further clarification?
Yes No
If yes, please explain:
____________________________________________________________________________
To
the best of my knowledge, all of the preceding answers and
information provided are true and correct.
If I ever have any change in my health, I will inform the
doctors at the next appointment without fail.
_________________________________________________________________
Date:________________
Signature
of patient, parent or guardian
Referral
Information
Whom
may we thank for referring you to our practice? Another
patient, friend
Another
patient, relative
Dental
Office
Yellow
Pages
Newspaper
Internet
Work
Other__________________
Name of person or office referring you to our practice: ______________________________________________
The
following is for:
the
patient's spouse
the
person responsible for payment
Name:
Male
Female
Married
Single
Child
Other
Social
Security #: ________________________________
Birth Date:
Phone (Home): ________________ (Work): ________________
Ext:______ Best time to call:
Address:
Street
Apartment
#
City
State
Zip Code
Employer
Name:
Occupation:
Address:
Street
City
State
Zip Code
Name
of Insured: _______________________________________________
Is insured a patient?
Yes
No
Last
First
MI
Insured's
Birth Date: _________________
ID #: _____________________
Group #:
Insured's
Address:
Street
City
State
Zip Code
Insured's
Employer Name:
Address:
Street
City
State Zip
Code
Patient's relationship to insured:
Self
Spouse
Child
Other___________________
Insurance Plan Name and Address: _________________________________________________________________
Bring insurance card to the office at each visit
As
a condition of your treatment by this office, payment is expected as
services are rendered unless prior financial arrangements have been
made in advance.
The practice depends upon reimbursement from the patients for
the costs incurred in their care and financial responsibility
rests on the patient or responsible party
All
emergency dental services, or any dental services performed without
previous financial arrangements, must be paid for in cash at the
time services are performed.
I
will not present for any dental treatment while under the influence
of alcohol or any illegal drug.
Patients
who carry dental insurance understand that all dental services are
charged directly to the patient and that he or she is personally
responsible for the account. This office will help patients prepare
insurance forms as a courtesy to the patient, but payment for
services rendered are ultimately the patients’ responsibility as
is an understanding of the terms of their policy.
This office cannot be responsible for knowing all the terms
of your insurance coverage, and cannot render services on the
assumption that our charges will be paid by an insurance company.
A
service charge of 1½ % per month (18% per annum) on the unpaid
balance will be charged on all accounts exceeding 60 days, unless
previously written financial arrangements are satisfied.
I
understand that the fee estimates listed for this dental care can
only be extended for a period of three months from the date of the
patient examination.
I
understand that I must provide 24-hour notice prior to the
cancellation of any dental appointment, or that I will be charged a
rate of $35.00 per 30-minute increment of time that was scheduled.
I
understand that there is a $25.00 charge for any check that is
returned non-collectable by my bank.
There
has been considerable disagreement in the dental profession with
regard to the safety of amalgam fillings.
In this practice, we do white (tooth colored) fillings unless
the patient specifically requests amalgam fillings.
White fillings may or may not be covered fully or partially
by your insurance carrier. It
is the patient’s responsibility to be informed with regard to this
provision.
In
consideration for the professional services rendered to me by the
Doctor, I agree to pay to the Doctor or his assignee at the time
services are rendered, or within the agreed time period.
I agree to pay all attorney fees and court costs incurred if
the practice is forced to take legal action in the collection of my
account
I
grant my permission to you or your assignee, to telephone me at home
or at my work to discuss matters related to this form.
I
have read the above conditions of treatment and payment and agree to
their content.
____________________________________________________
Date: _____________ Relationship
to Patient:
Signature of patient, parent or guardian
____________________________________________________
Date: _____________ Relationship
to Patient:
Signature of guarantor of payment/responsible party