Patient Intake Form - Advanced Dental Esthetics

Patient Information

Salutation(Required)

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

SSN(Required)

Sex(Required)

Date of Birth(Required)

Marital Status

Cell Phone No

Work Phone No

Additional Phone No

Are any of your family members our patients?

Yes

If Yes, Who?

How did you hear about us?

Emergency Contact Information:

First Name(Required)

Last Name(Required)

Relationship(Required)

Best Contact Phone No(Required)

Primary Dental Insurance

Name of Insurance Co.

Relationship

Phone No

Subscriber’s Name

Date of birth

Employer’s Name

SS No./ID No

Employer’s Address

Street Address Address Line 2 City State ZIP Code

Group No

Secondary Dental Insurance

Name of Insurance Co.

Relationship

Phone No

Subscriber’s Name

Date of birth

Employer’s Name

SS No./ID No

Employer’s Address

Street Address Address Line 2 City State ZIP Code

Group 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

Previous Dentist’s Name

Phone No

Last Dental Visit

Are you having any pain or discomfort at this time?

Yes

Have you ever had a full mouth x-rays taken of your teeth?

Yes

If yes, when?

Have you ever had treatments for your gums?

Yes

Do your gums hurt or bleed when you brush?

Yes

Do your teeth hurt when you chew?

Yes

Have you ever had orthodontic treatment or worn braces?

Yes

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

Yes

Are your teeth sensitive to hot, cold or sweet?

Yes

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

Yes

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

Yes

Are you on a special diet?

Yes

Do you use a tobacco products?

Yes

What and how much

Do you use alcoholic beverages?

Yes

How much

How often

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

Yes

For what

Have you been under the care of a medical doctor during last past years?

Yes

For what

Are you taking any other medicine, drug or pills?

Yes

If yes, please list

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

List

Check any of the following you have had or have at present

List any other condition not listed above

For Women Only

Are you now or think you may be pregnant?

Yes

Are you nursing?

Yes

Are you presently taking birth control pills?

Yes

Authorization & Release

I certify that I have read and understand the above information to the best of my knowledge. I have answered the above questions accurately. I understand that providing incorrect information can be dangerous to my health. 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 third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill of services. I agree to be responsible for payments for all services rendered on my behalf or my dependents.

Signature of patient, parent or guardian

Date

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 hospitalization or death. Granted these are fairly uncommon occurrences but individuals who are contemplating this should be aware of this prior to consenting. Whenever drilling is involved, 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 persist 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

Date

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

Date

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 understand 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. Accounts delinquent more than 60 days from 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.

Signature

Date

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 the 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 advance.

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, and 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.

I HAVE READ AND UNDERSTAND THE ABOVE DENTAL OFFICE INFORMED FINANCIAL POLICIES.

Signature of responsible party

Date

Please print your name

By submitting this form, I agree to receive emails with related information and updates, and understand I can change my preferences at any time. See our Privacy Policy.

REQUEST APPOINTMENT

Patient Registration Form

Patient Information

Emergency Contact Information:

Primary Dental Insurance

Secondary Dental Insurance

Health History

For Women Only

Authorization & Release

DENTAL OFFICE INFORMED CONSENT

Notice of Privacy Practices Patient Acknowledgement

Patients Without Insurance Coverage

Office Policy

Our Financial Policy

Monday:	8:00AM – 5:00PM
Tuesday:	8:00AM – 5:00PM
Wednesday:	8:00AM – 5:00PM
Thursday:	8:00AM – 6:00PM
Friday:	8:00AM – 3:00PM
Saturday:	8:00AM – 1:00PM (Alternating Saturdays)