Whom may we thank for referring you? About You. Name: I prefer to be called [] Male [] Female. Home Address: City State Zip

Transcription

1 We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions or need assistance, please ask us we will be happy to help. Whom may we thank for referring you? About You Name: I prefer to be called [] Male [] Female [] Single [] Married [] Child [] Other Birth Date: / / Age: S.S. #: Home Address: City State Zip Home Phone: ( ) Work: ( ) ext. Pager: ( ) Cell: ( ) Address: Employer: How long there? Occupation: Employer s Address: City State Zip Person Responsible For Account [] Same as above name: Birth Date: / / Relation: Billing Address: City State Zip Home Phone: ( ) Work: ( ) S.S. #: Employer: How long there? Occupation: Spouse Information Name: Birth Date: / / Employer: Work Phone: ( ) ext.

2 Emergency Contact Emergency Contact (not living with you): Relationship Home phone: ( ) Work: ( ) Cell: ( ) Primary Insurance Dental Insurance Information Insurance Co. Name: Phone: ( ) Member ID #: Group/Policy #: Insured s Name: Insured s Birth date: / / Relation: Insured s Social Security #: Insured s Employer: Secondary Insurance Insurance Co. Name: Phone: ( ) Member ID #: Group/Policy #: Insured s Social Security #: Insured s Employer: Insurance Authorization / Assignment I hereby authorize Southern Dental Care to furnish to my insurance carriers any information necessary to process any claim for services rendered by Southern Dental Care s dentists. I hereby assign to these same dentists any insurance benefits payable for services rendered to my dependents, or myself but not to exceed my indebtedness to Southern Dental Care. I understand I am financially responsible for all services rendered regardless of insurance coverage. DATE SIGNATURE (Parent if patient is a minor)

3 Appointments Initial We value your time so you can expect us to see you at the appointed occasion and to keep your period spent in our office as short as possible. In return, when you make an appointment with us please be on time since we have reserved our time just for you. Please make every effort not to change your scheduled appointment. If you must change an appointment, please provide us at least 2 working days advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. Missed appointments will result in a $25.00 fee. We value your time. Please value ours. We have a very convenient text/ reminder system that we offer to our patients. We are asking all of our patients to give permission to /text your appointment time/date openings to you for a reply to confirm, cancel, or schedule. Everyone that gives permission will have the ability to opt out at a later date Initial I give permission to /text my appointment date, time and openings in their schedule to my cell phone and/or . Cell phone #: address: Financial Policy Initial Dental insurance plans often pay less than the actual fee for service, therefore the patient or Guarantor is the responsible party for all dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be explained to you during the Treatment Discussion appointment. Your estimated patient option is only an approximation and is based on your estimated insurance benefits. We are NOT responsible for any agreement between you and your insurance company. As a courtesy to you, we will be happy to file with your insurance company. To keep our fees to you as low as possible, we ask that you pay your ESTIMATED copayment as the time you receive treatment. Also, we do not down grade fees or insurance code changes (any difference in fee will be your responsibility). Initial Unless another financial option is PRE-ARRANGED, payment in full is due the day of treatment, or on pre-op visits for sedation appointments. Should a patient have dental insurance with assignment to Southern Dental Care, the estimated patient portion will be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full. Payment Options 1. For your convenience we accept Cash, Check, Visa, MasterCard, Amex, & Discover. 2. We also offer short and long-term financing options. (Interest-free options, known as Care Credit, may apply)

4 Authorization and Consent General Consent to Treatment Initial I agree and consent to a dental examination by Dr. Lacey Andreotta. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed. Release of Information Initial I authorize Southern Dental Care to release any information regarding my dental/medical history, diagnosis or treatment to the third party payers and/or other health professionals. Assignment of Insurance Benefits Initial I authorize and request my insurance company to pay my benefits directly to Southern Dental Care. Patient Health Information NAME DATE Chief Complaint (Why are you seeking dental care?) Current State of Health Are you in good health?... YES NO Are you currently under the care of a health physician?... YES NO Please list your family physician and any medical specialists you see at least once a year: Name Address City Phone # Name of Specialty

5 Medical History 1. Do you have (or have you ever had) any of the following? YES NO a. Allergic reaction to drugs or latex (circle all that apply) Latex Aspirin Penicillin Codeine Local Anesthetics YES NO b. Heart attack or heart disease YES NO c. Stroke YES NO d. High blood pressure YES NO e. Congestive heart failure YES NO f. Angina (chest pains) YES NO g. Irregular heart beat YES NO h. Artificial heart valve YES NO i. Rheumatic fever, rheumatic heart disease, bacterial endocarditis YES NO j. Congenital heart disease YES NO k. Heart murmur of mitral valve prolapse YES NO l. Immunosuppressive condition (circle all that apply) Steroid Therapy (e.g. prednisone) Radiation or Cancer Therapy SLE (Lupus) Rheumatoid Arthritis HIV Organ Transplant Spleen removal Other YES NO m. Artificial joint(s) (Circle all that apply) Hip Knee Ankle Shoulder Date(s) placed: YES NO n. Other artificial implants or devices YES NO o. Bleeding problems, anemia, other blood disease YES NO p. Diabetes YES NO q. Thyroid Disease YES NO r. Long-term antibiotic use (greater than one month continuously) YES NO s. Nervous system disease or seizures YES NO t. Kidney disease YES NO u. Hepatitis (A, B, C, or D) or other liver disease YES NO v. Muscle or joint disease or other arthritis (osteo or rheumatoid) YES NO w. Asthma, tuberculosis, or other lung disease YES NO x. Mental health condition specify: YES NO y. Stomach or intestinal disease YES NO z. Physical or mental disabilities that may require special care? YES NO 1. Impairment of hearing, sight, or speech? YES NO 2. Do you have or have you ever been treated for cancer? YES NO 3. Are you or could you be pregnant or are you nursing?

6 YES NO 6. Do you have any undiagnosed symptoms? YES NO 7. Are you, or have you ever been addicted to chemical substances? YES NO 8. Do you currently drink alcohol or use recreation drugs? YES NO 9. Do you smoke or use smokeless tobacco? If so, what type? 10. How interested are you in stopping your tobacco use? YES NO 11. Do you regularly take herbal medicines or dietary supplements? (Circle all that apply) Echinacea Garlic Ginger Kava Valerian Feverfew Gingko Ginseng St. John s Wort Vitamin E Omega Three Fish Oils YES NO 12. Have you undergone current or past therapy for osteoporosis? Calcium (bisphosphonate therapy) Examples: Intravenous Aredia, Zometa, and Boniva Dental History YES NO 13. Do you have regular dental check-ups? Date of last exam: YES NO 14. Have you had any trouble associated with previous dental treatment? YES NO 15. Have you noticed any lumps or sores in your mouth? YES NO 16. Do your gums bleed when you brush your teeth? YES NO 17. Have you ever injured your face, jaws, or teeth? YES NO 18. Do you suffer from pain in the mouth, face, eyes, neck, or throat? YES NO 19. Are you happy with the appearance of your teeth? YES NO 20. Do you want to save your teeth? YES NO 21. Has fear ever prevented you from seeking dental treatment? YES NO 22. Are you allergic to any metal or dental materials? 23. Circle the types of dental treatment you have experienced: Orthodontics (Braces) Dentures Root Canal Treatment Implants Oral Surgery Periodontal (gum) treatment TMJ treatment Fillings * Please list all medications that you are currently taking: Southern Dental Care requests this information for the purpose of providing a complete and comprehensive evaluation of your dental needs. No persons outside the practice will be provided with this information unless properly authorized by you or required by law. Failure to provide the requested information will limit our ability to assess your needs and may result in our practice being unable to accept you as a patient. By signing below, you agree that the information given is accurate and that you will notify our office of subsequent appointments if there are any changes in your health. Patient signature: Date: (or) Patient s representative: Relationship to patient:

7 NOTICE OF PRIVACY FOR PROTECTED HUMAN INFORMATION I hereby acknowledge that I have received a copy of this practice s Notice of Privacy Practices. I understand that I may ask any questions I might have regarding this notice. Printed Name Date Signature Date FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)