As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Dental Information

Medical Information

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Primary Dental Insurance

Secondary Dental Insurance

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Patient Screening

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

APPOINTMENTS

An appointment has been especially made for you, please remember that this time has been reserved for you. Please understand there will be a $50 charge to your account for broken appointments without at least a 24-hour notice to cancel the appointment.

PAYMENT OPTIONS

PAYMENT IS DUE ON THE SAME DAY TREATMENT IS RENDERED OR RECEIVED.

NOTE: THERE IS A $50 CHARGE ON ALL RETURNED CHECKS.

DENTAL INSURANCE

We are happy to file the forms necessary to see that you receive the full benefits of your insurance coverage, however, we cannot guarantee any estimated coverage, including preauthorizations. Therefore, we ask that all patients be directly responsible for ALL charges. Please know that we will do everything possible to see that you receive the full benefits of your policy. If for some reason your insurance company does not pay their expected portion of your bill within 30 days from the start of treatment, you will be responsible for the payment at that time. You are also responsible for any deductibles, co-payments, non-insurance covered procedures, or any amount due not paid by your company.

REFUND POLICY

It's office policy that any funds due to patients will be credited in the form of payment for future services or to resolve past balances. The office has a No Refund Policy.

COLLECTION

All delinquent accounts will be referred to a COLLECTION AGENCY after 60 days due unless payment arrangements have been made. The patient or guarantor of the account will be responsible for all collection fees, court costs, attorney fees or any cost involved in collection of the account.

OFFICE CASH/CHANGE POLICY

We are not able to guarantee change in the form of cash tender for your payments. Card payments are preferred but in the event you need to resolve your account with cash, please accept a credit on your account going towards future treatments or to resolve past balances, if change is due to you.

RECORDS RELEASE

In the event that you need to obtain your dental records, we are happy to assist and provide those to you. Providing records includes time to retrieve x-rays and chart notes. In some events, if the report is detailed we need to print said records and mail them. For the office time, we request a minimal charge of $25 be satisfied to obtain these records in a timely fashion (usually within 72 hours). Thank you in advance for understanding.

SUPPLIES/WASTE & DISPOSAL, PPE EQUIPMENT

Many of our products & supplies are shipped from various distributors & suppliers within & outside of the US. In this economic and political climate we are seeing substantial increases in transportation and delivery costs that have resembled Covid-19 pricing and shortages. During Covid times we implemented a $20 PPE charge that most patients graciously understood. Due to rising costs of supplies, the cost to dispose properly of biohazardous materials in a safe and environmentally friendly fashion, we are implementing a SWE charge of $35 to all new patient examinations, periodic 6-month exams, and follow up treatment visits. In certain instances- such as if you visit us for a crown preparation appointment and return in 10 days for your delivery appointment, you would only see the SWE charge reflected on the first visit, not subsequent delivery appointment(s). We thank you in advance for your understanding and support of us as a small neighborhood practice combating inflation and supply shortages.

CONSENT

The undersigned hereby authorizes the doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis and treatment plan for the patient's dental case.

I understand that my dental insurance (if applicable) is a contract between the insurance carrier and me and not between the insurance carrier and the Doctor (different Provider Agreement) and I am still fully responsible for all dental fees not paid by the insurance company. I understand that if I am uninsured that all dental fees are my responsibility and I accept treatment and fees associated with that treatment. I agree to resolve any balances when services are rendered. All deductibles and co-payments are due at the time service is rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor/Office. If for some reason, I receive a check or payment from the insurance company for services rendered at this office I will either return to the insurance company or forward to this dental office the received payment.

Any payments received by the Doctor from my insurance company will be credited to my account if I have paid the dental fees incurred. I further understand that a late charge equal to 5% of the monthly amount due will be added to any overdue balance. I understand that at a later time, credit reports may be obtained.