Prince Family Dentistry

Transcription

1 Prince Family Dentistry S. Durango Dr., Ste. 104 Las Vegas, NV PATIENT INFORMATION Last Name First Name MI Preferred Name Birthdate {Male { Female SS# {Minor { Single { Married { Divorced { Widowed { Separated Address City State Zip Home Phone ( ) Cell Phone ( ) Patient s/parent s Employer Work Phone ( ) Employer Address City State Zip Spouse/Parent s Name Employer Emergency Contact Phone ( ) Is there someone we can thank for referring you to our office? Name If not, how did you hear about us? RESPONSIBLE PARTY Last Name First Name MI Address City State Home Phone ( ) Cell Phone ( ) Social Security # Birthdate Employer Employer's Address Work Phone ( ) Relationship to Patient Currently a Patient in our Office? { yes { no Dental Insurance Information Relationship Policy Holder's Name to Patient Birthdate SS# Employer Work Phone ( ) Employer Address City State Zip Insurance Co. Phone # Member # Address City State Zip DO YOU HAVE ANY ADDITIONAL/SECONDARY INSURANCE? { Yes { No IF YES, COMPLETE THE FOLLOWING: Additional/Secondary Dental Insurance Information Relationship Policy Holder's Name to Patient Birthdate SS# Employer Work Phone ( ) Employer Address City State Zip Insurance Co. Phone # Member # Address City State Zip *Please note that the person responsible for this account will be responsible for ALL charges not covered by the insurance company, at the time of service.

2 ASSIGNMENT AND RELEASE I, the undersigned, have insurance with Name of Insurance Company(ies) and assign directly to Dr. Douglas Prince all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. MINOR/CHILD CONSENT Signature I, being the parent or guardian of do hereby request Name of minor/child and authorize the dental staff to perform necessary dental services for my child, including but not limited to X-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered. Signature of Insured/Guardian FINANCIAL AGREEMENT I acknowledge that payment is due at the times of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance. Signature of Insured/Guardian MEDICAL HISTORY UPDATE Has there been any change in your health since your last dental appointment? { Yes { No For what conditions? Are you taking any new medications? If so, what Patient Signature Dentist Signature MEDICAL HISTORY UPDATE Has there been any change in your health since your last dental appointment? { Yes { No For what conditions? Are you taking any new medications? If so, what Patient Signature Dentist Signature

3 DENTAL HISTORY Reason for today s visit of last dental exam How often do you floss? How often do you brush? Describe any dental problem What, if anything, would you change about your smile? Do you have any of the following? { Bad breath { Clicking or popping jaw { Sensitivity to cold { Grinding your teeth { Pain when biting { Sensitivity to heat { Bleeding gums while brushing or { Sores or growths in your mouth { Sensitivity to sweets flossing { Surgery to mouth or gums { Food Collection between teeth { Loose teeth or broken fillings { Periodontal treatment { Radiation treatment MEDICAL HISTORY Physician s Name of last visit Have you had any serious illnesses, surgeries or hospitalization? { Yes { No If yes, describe Are you under a doctor s care now? { Yes { No If yes, for what? Have you had a change in your health in the past year { Yes { No If yes, describe Have you ever been told you need to be pre-medicated or take antibiotics before dental work? { Yes { No If yes, for what? Is there anything else we should know about your medical history (Women) Are you pregnant? { Yes { No Nursing? { Yes { No Taking birth control pills? { Yes { No If patient is a child, what is his/her weight? Do You have or have you had any of the following: { Heart Murmur { Allergies to Anesthetics { Rheumatic Fever/Scarlet Fever { Allergies to Medicine or drugs { Mitral Valve Prolapse { Bleeding Disorders { Pacemaker { Sickle Cell Disease/trait { Bypass Surgery date { Hemophilia { Artificial Heart Valves { HIV/AIDS or Joints { Thyroid Disease { High Blood Pressure { Stroke { Low Blood Pressure { Persistent Cough { Circulatory Problems { Tuberculosis { Diabetes { Kidney Disease { Respiratory Disease/Asthma { Cancer { High Cholesterol { Chemotherapy { Hepatitis, Jaundice or Liver Disease { Radiation Treatment { General Allergies { Nervous Problems { Arthritis { Jaw Pain { Swollen Neck Glands { Headaches { Sinus Problems { Psychiatric Care { Epilepsy { Chewing Tobacco { Chemical Dependency { Ulcer { Venereal Disease Do you have any drug allergies or have you ever had any adverse reaction to any medication? If so, what Have you ever responded adversely to medical or dental treatment? List any medication (Doctor prescribed or over the counter) The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits. I will not hold Dr. Prince or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. Signature of Patient or Parent If Minor

4 Prince Family Dentistry "Creating Smiles that Last a Lifetime" S. Durango Dr., Ste. 104 Las Vegas, NV Please Read Carefully Welcome to Prince Family Dentistry! Thank you for choosing to join our family at Prince Family Dentistry. We work hard to ensure your visit with us is the easiest and most enjoyable experience you've ever had in a dental office. If there is anything we can do to make your visit more comfortable or convenient, please let us know. Appointment Agreement: We go out of our way to provide extra time for you and Dr. Prince and/or the hygienist to discuss your dental health concerns and to discuss treatment plans that work best for you. We ask that you be present for all of your scheduled appointments. We treat any appointment as a bond of trust between you and us that we will be there to serve you, and you will be present for the appointment. Therefore, we do not allow frequent cancellations or changes in appointment times with less than a 24 hour notice. Appointments cancelled with less than a 24 hour notice will be charged a $35 fee per hour. Insurance Made Easy: For your convenience, we will file and submit your insurance claims for you. Please remember that your insurance policy is a contract between you and your insurance company. We are not a party to that contract. It is physically impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer has purchased for you. As a courtesy to you, our office will send in a pre-authorization to your insurance company. If you have any questions concerning the pre-authorization and/or fees for service, it is your responsibility to have these answered prior to treatment to minimize any confusion on your behalf. Please note that after 60 days, any unpaid or outstanding insurance balance will be due by you, the patient. While we file claims for you as a service, it is your responsibility to maintain and understand your insurance benefits. All problems with insurance are between the patient and the insurance company. Payment/Financing Options: Payments may be made to this office with cash, personal checks, Visa, Mastercard, American Express and Discover cards. We also accept telephone credit card authorizations. We want to make this aspect of your dental treatment as easy as possible. Our front desk personnel can explain these options to you in more detail. In the case of children of divorced parents, the custodial parent will be financially responsible for providing this office with payment, regardless of divorce settlement. All minor patients should be accompanied by an adult. This adult is responsible for payment of services performed on the minor at the time of service. For those without dental insurance or for more extensive needs we offer financing through Care Credit for those approved. If you are in need of financing options, please discuss your financial needs with the front desk before scheduling treatment.. Financial Responsibility: You can expect to see monthly statements from Prince Family Dental until your account is paid in full. You will be responsible for your portion of payment plus any unmet deductibles on the day of service. It is important to understand that you, the patient, are responsible for all fees incurred from your visit An account becomes over due after 90 days and will be charged a $25 late fee for every month the balance remains unpaid. You're responsible for all fees incurred while collecting unpaid balances. Collection Policy: You agree to be financially responsible for all charges incurred regardless of insurance coverage.. In the event your account is referred to a collection service due to lack of payment on your part, you will be charged a 30% collection fee and will be discharged as a patient of Prince Family Dental. Returned Checks: There will be a $25 fee for all returned checks. If a check is returned, you will be expected to pay by cash, credit card or money order on all subsequent service charges. We wish to thank you for choosing us as your dental treatment provider. If at any time you have questions regarding any treatments, fee, or service, feel free to discuss your concerns with us. I have read the above policy and agree to its terms and conditions. Signature of Patient (Parent or Guardian if minor) Patient s Name (Please Print)

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