212 SE 12 th Street - Fort Lauderdale, FL Patient Information
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1 Name Patient Information What is the reason for today s visit? How did you hear about our office?(person s name if any)_ Is there anything about your smile that you do not like? How long since your last visit to the Dentist? Why did you leave your last dentist? How long would you like to keep your teeth? Are you interested in knowing the options available for a more beautiful smile? Y or N How would you rate the appearance of your teeth? Are all of your teeth in alignment (straight)? Yes or No (Poor) (great) Do you have any missing teeth? Yes or No Are any Broken/ chipped? Yes or No Is your bite comfortable when chewing, biting? Do you have frequent headaches? Yes or No Yes or No Do you have any old metal fillings or dental treatment that you are unhappy with? Yes or No What would you like to change the most about the appearance of your teeth? Favorite foods? Favorite Music? Active in Hobby or Sports? Please give us your Facebook ID for special online promotions What expectations do you have of this Dental Office as your oral healthcare provider?
2 Welcome to our Dental Office! We warmly welcome you to our office. Please take a few moments to read the following information so we can better serve you. It is our goal to help you reach and maintain maximum oral health. Standard of Care We are true believers that preventative care and patient education are the keys to optimal dental health. We strive to provide dental health care vs. disease care. That's why we focus on thorough exams checking the overall health of your teeth and gums, performing oral cancer exams, and taking x-rays per standard of care. We also know that routine cleanings, flossing, sealants, and fluoride are all helpful in preventing dental disease. Not only are we focused on the beauty of your smile, but we are also concerned about your dental health. A review of your medical history, updated once a year, can help us stay informed of your overall health, any new medications, and any illnesses that may impact your dental health. A note for our patients with dental insurance: We will assist you in anyway possible to maximize your insurance benefits. We are happy to file claims to your insurance company. We will do our best to make as close of a calculation as possible of what your insurance plan will cover however regardless of what your insurance plan pays for you, you are responsible for all fees. Payment Arrangements: Payment is due when treatment is rendered. We do offer financing through Chase and Care Credit, some with no interest. Please note that a late fee of $10.00 a month will be added to your balance after 60 days. Should your account ever be sent to collections, a 10% collection fee will be added to your balance. Appointment Cancellation Policy: Please help us deliver the best quality dental care by keeping scheduled visits. We do not double book, your appointment time is reserved just for you! We do our best to run on time and in return ask that you value our time. If you are unable to keep an appointment we kindly ask that you give us at least 48 working hours notice. Please call us during working hours if you need to cancel your appointment. We reserve the right to charge $75 per hour for appointments cancelled with less than adequate notice. I have read and understand the above information: Signature of Patient or Legal Guardian Print Name of Patient or Legal Guardian Date Witness
3 Patient Photo Consent Form I,, do hereby give my consent to Yanitza McConnell DMD for the use of my dental photos, videos, and/or portrait for the advancement of cosmetic dentistry, educational viewing by other dental professionals, and in the promotion of cosmetic dentistry without my name. I release and forever discharge him from any claims, demands or liabilities on account of such use. Before and after photos may be used to present future case studies to patients, used on our dental web site, as well as in our office slide show. Thank you for your time and cooperation. Signature Date I am the parent or guardian of the minor named above and have the legal authority to execute the above releases. I approve the foregoing and waive any rights in the premises. Parent Signature Date
4 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent, the office of Yanitza McConnell, D.M.D. may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment and healthcare Operations (TPO). Please refer to our office's Notice of Privacy Practice for a more complete description of such uses and disclosures. With my consent, the office of Yanitza McConnell, D.M.D. may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, the office of Yanitza McConnell, D.M.D. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. By signing this form, I am consenting to the office of Yanitza McConnell, D.M.D. use and disclosure of my PHI to carry out TPO. If I do not sign this consent, the office of Yanitza McConnell, D.M.D. may decline to provide treatment to me. With my consent, the office of Yanitza McConnell, D.M.D. may disclose my PHI to carry out TPO to the following selected area(s): Dentist/Specialist Physician Legal Guardian Power of Attorney Relative(s) Other Signature of Patient or Legal Guardian Print Name of Patient or Legal Guardian Date Witness
5 Are you able to identify your bite? Crowding Overjet Spacing Crossbite Deep Bite Underbite Open bite Other: What style of treatment do you prefer to correct this bite? Metal braces Invisalign Clear braces
6
7 212 SE 12th Street - Fort Lauderdale, FL 33316
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NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY
NOE VALLEY SMILES FOR KIDS PEDIATRIC DENTISTRY Date: Patient Information Child s Full Name Age Sex (M) (F) Nickname (if any) Birth Date Whom may we thank for referring you General Information Mother/ Father
Your Smile: Braces By Blalock
Your Smile: Braces By Blalock Malocclusion: Bad Bite Can lead to: Tooth decay Broken teeth Gum disease Tooth loss Orthodontist A dental specialist in the diagnosis, prevention and treatment of malocclusions
Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
MEDICAID REIMBURSEMENT
MEDICAID REIMBURSEMENT Medicaid for children under 20 Pays for exam, cleaning, and fluoride treatment every six months. $100 of x-rays per year. Pays for fillings, sealants, extractions, stainless steel