EMERGENCY INFORMATION Person to Contact: Relationship: Phone: Address:

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Damon Chambers
5 years ago
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WELCOME. We are a general (family) and cosmetic dental practice.

function, and the overall smile that you desire. In order to help us achieve this, we ask that you take a few minutes to review and complete the following forms.

The additional forms exist to serve you, our patient, as they provide important information regarding treatment diagnosing, treatment scheduling, dental insurance, financial agreements and payment

1 WELCOME. We are a general (family) and cosmetic dental practice. The benefits of a healthy, beautiful smile are immeasurable, and our goal is to provide you with knowledge and options which allow you to reach and then maintain maximum oral health, stable bite and function, and the overall smile that you desire. In order to help us achieve this, we ask that you take a few minutes to review and complete the following forms. These forms provide us with the necessary medical, dental and insurance information we need to serve you in the best way possible. The additional forms exist to serve you, our patient, as they provide important information regarding treatment diagnosing, treatment scheduling, dental insurance, financial agreements and payment options. We have developed this information packet with the help of our own patients over many years as they expressed the desire to have more knowledge about practice procedures, the complexities of dental insurance and office policies. We hope you find it helpful and informative. Please complete these forms and bring them with you to your appointment. Thank you. ABOUT YOU Name: Female Male Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Birth Date: / / Marital Status: Single Married Widowed Address: Name of Spouse: _ Spouse Birth Date: / / Names of Children: Whom can we thank for referring you? EMERGENCY INFORMATION Person to Contact: Relationship: Phone: Address: INSURANCE INFORMATION Subscriber Name:_ SSN or Alt ID#: Insurance Company: _ Employer: Insurance Phone Number: Group#: I agree that I am financially responsible for all fees related to dental services and materials rendered at this office. I understand that if I carry dental insurance, the office will assist me in filing my dental claims once I have provided the necessary information. I authorize the release of the necessary information relating to my dental insurance claims as permitted under applicable law. I also authorize payment of dental benefits, otherwise payable to me, to be paid directly to D. Greg LoPour DDS, Smiles By Design, PA. Signature of Patient or Responsible Party Today s Date

2 ALLERGIES Please check if you re allergic to any of the following: Local anesthetics Sulfa drugs Codeine/other narcotics Antibiotics list: Barbiturates, sedatives, sleeping pills Shellfish, iodine Other Have you ever had any serious illnesses? If yes, please explain: MEDICAL HISTORY Name of Physician: Address: Phone Number: Approximate date of last visit: Current health condition: Excellent Good Fair Poor Have you had any serious health problems in the last five years? yes no If yes, please explain: (For women) Are you currently pregnant? yes no If yes, how many months? Please list prescription medications: Please list vitamin/herbal supplements: When a health care worker is exposed to my blood or body fluids through a needle stick, cut or splash to the eye or mouth, I agree to have my blood tested for blood-borne diseases to include Hepatitis B and C Virus and Human Immunodeficiency Virus (AIDS). Initial: Have you ever had: AIDS/HIV Positive Easily Winded Herpes Sickle Cell Disease Alzheimer's Disease Emphysema High Blood Pressure Sinus Trouble Anaphylaxis Epilepsy or Seizures Hives or Rash Spina Bifida Arthritis/Gout Excessive Bleeding Hypoglycemia Stomach/Intestinal Disease Artificial Heart Valve Excessive Thirst Irregular Heartbeat Stroke Artificial Joint Fainting Spells/Dizziness Kidney Problems Swelling of Limbs Asthma Frequent Cough Leukemia Thyroid Disease Blood Disease Frequent Diarrhea Liver Disease Tonsillitis Blood Transfusion Frequent Headaches Low Blood Pressure Tuberculosis Breathing Problem Genital Herpes Lung Disease Tumors or Growths Bruise Easily Glaucoma Mitral Valve Prolapse Ulcers Cancer Hay Fever Pain in Jaw Joints Venereal Disease Chemotherapy Heart Attack/Failure Parathyroid Disease Yellow Jaundice Chest Pains Heart Murmur Psychiatric Care Other Cold Sores/Fever Blisters Heart Pace Maker Radiation Treatments Congenital Heart Disorder Heart Trouble/ Disease Recent Weight Loss Convulsions Hemophilia Renal Dialysis Cortisone Medicine Hepatitis A Rheumatic Fever Diabetes

3 DENTAL HISTORY On a scale of 1 to 5 (1 low, 5 high), please rate: How do you feel your overall dental health is: What is your level of sensitivity to dental procedures? How do you feel about your smile and the look of your teeth: How often do you have your teeth cleaned? Would you like to improve your existing smile? yes no If Yes, Please answer the following questions: Do you dislike the color of your teeth? yes no Do you have spaces between your teeth that bother you? yes no Do you have chips or uneven edges on your teeth? yes no Do you have silver fillings that show when you smile? yes no Do you feel your teeth are crowded or crooked? yes no Do you have existing crowns or dental work you are currently unhappy with? yes no Do you feel self-conscious of your teeth when you smile? yes no Do you avoid smiling when you have your picture taken? yes no Date of your last dental hygiene visit? / / What is the main reason for your visit today? Tooth pain Cleaning Orthodontics (braces) Whitening Cosmetic dentistry Sedation dentistry Other Have you ever been treated for TMJ or joint pain? yes no Do you suffer from headaches? yes no If so, Tension or or Migraine Muscle tenderness in jaw/teeth? yes no I am interested in learning more about: (check all that apply) Orthodontics Bridges Whitening Cosmetic dentistry Implants Sedation dentistry Veneers Dentures Other The information I have given is true and accurate to the best of my knowledge. Signature of Patient or Responsible Party Today s Date

4 **THIS PAGE COMPLETED BY HYGIENIST / DENTIST ORAL EXAM Calculus Deposits: Slight Moderate Excess Plaque Present: Slight Moderate Excess Inflammation: Slight Moderate Excess Perio Follow-up: Perio Type: General Condition of Teeth: Good Fair Poor General Condition of soft Tissue: Good Fair Poor Pain in Joint: Occlusion: Recession: Occlusal Wear: Bone Loss: When were teeth extracted: Smile Analysis: Blood Pressure: O.C.E.: O.S.: OTHER: PERIO: OTHER: SUBJECTIVE INFORMATION Home Town: Date Moved to ABQ: Relocated From: School & Grade: Hobbies: PERSONAL INFORMATION NOTES

5 Commitment to Financial Agreement and Payment for Services After X-rays and an examination, we provide a detailed treatment plan and estimated treatment fees. All estimates are based on conditions viewed at the time of diagnosis. Please understand that some teeth may have hidden decay or affected nerves that may require additional x-rays and more extensive dental treatment that require additional fees. A financial agreement will be documented accordingly. In the interest of responsible dental care practice, and to avoid misunderstandings between patient and dental office, it is important to identify the different payment practices that are accepted by this office.! For your convenience we will accept cash, check, debit, Visa, MasterCard, Discover and American Express.! Although dental insurance is the responsibility of the patient, we will gladly bill your insurance company on your behalf when you provide us with all pertinent insurance related information.! Any questions regarding that coverage will be addressed between you and your insurance company. We strive to be advocates for our patients in a complex world of dental insurance. We are not the insurance company. We have no control or involvement regarding the benefits provided to you by your employer or your individual insurance plan.! We strive to help inform our patients regarding the complexities of insurance eligibility and insurance benefits. We will estimate (to the best of our ability) how much we think an individual s insurance plan will pay toward the treatment rendered. This is not a guarantee. Once treatment is rendered and we have filed your claim, it can take up to 90 days or longer to receive an EOB (Explanation of Benefits) and payment. Monthly statements will continue to be mailed. We appreciate your continual patience during this time period. (Please read the enclosed ADA brochure regarding dental insurance).! We provide for all patients a Financial Agreement if any dental treatment is to be performed. This allows our patients the advantage of a detailed treatment plan along with treatment fees, estimated insurance coverage for each procedure and the dollar amount which our patients are responsible. It is standard to collect 100% of the estimated patient portion on the day dental services are rendered. We want to help our patients receive the dentistry they need and desire, therefore we do offer payment plans. Please ask us to review these with you if you would like more information on payment plan options.! On procedures NOT submitted for insurance coverage, we offer a 5% discount if the balance is paid in full by either cash, check or debit card on the date of service.

6 Commitment to Treatment and Appointments A policy is a written statement of what actions or activities we will take in order to achieve a desired result. We have two important policies in our practice that we feel are important to share with you, our patient. We have put them in writing because we operate by them and we require that all of our patients adhere to them as well. These policies may differ slightly from previous dental offices; however we do believe they are very necessary to the success of this dental practice and our relationship with our patients. Please do not hesitate to ask questions regarding any aspects of these commitments. We are here to serve you. Commitment to Treatment We believe we have a responsibility to employ our best professional care, skill, and judgment in planning for your dental treatment. We believe that all treatment that is started will be completed. Incomplete treatment leads to problems, complications, and misunderstandings. Incomplete treatment could also lead to loss of teeth as well as to the possibilities of dental related diseases. Therefore, this policy states that all agreed upon treatment plans, once they are started, will be completed. Please realize that some treatment plans, because of their complexity in design, may take many months to complete. In order to begin any staged treatment, your commitment to both starting as well as completing treatment is necessary. In the event you should transfer your care to the care of another dentist while undergoing treatment here at our office, we will do everything possible to provide the needed information requested by you and your treating dentist; but we do not assume responsibility for treatment started here under Dr. LoPour and/or his associates that is not finished here. Therefore, if you leave in the middle of treatment, we cannot accept responsibility for failed treatment results or loss of teeth. Commitment to Appointment We reserve time for each patient in our practice. Your appointment, written into our calendar, is a bond of trust that we will be here to serve you and you will be present for that scheduled time. Due to the allocation of resources in order to meet the needs of our patients, we do not allow last minute cancellations (medical emergencies are an exception) or constant short-notice changes. Therefore, our office policy in regard to keeping appointments is extremely firm. We believe in mutual respect for each other s time. We have a Missed Dental Appointment Policy that states if a patient fails to show (or short notice cancels) more than one time for treatment scheduled with Dr. LoPour or one of his associate Dentists, we reserve the right to charge a fee which may equal 50% of the entire cost of the missed appointment. Emergencies and accidents do happen and we will make every effort to take that into consideration. We also have a Hygiene Cancellation Policy which is applicable to all patients of record of Dr. Greg LoPour and his associates. The policy charges $55.00 for missed hygiene appointments without a notification or an unforeseen emergency or illness. By signing below, you acknowledge that you have read this commitment form and understand its content, agree to its content including the Missed Dental Appointment Policy and the Hygiene Cancellation Policy. Patient Name: Patient Signature: _ Date: (Dr. D. Greg LoPour/Authorized Representative Signature): Date:

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Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,