Welcome to Renew Family Dentistry Joshua F. Maxwell DDS, FAGD, FICOI, PC 5575 Warren Parkway Suite 324 Frisco, Texas Office:
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1 Welcme t Renew Family Dentistry Jshua F. Maxwell DDS, FAGD, FICOI, PC 5575 Warren Parkway Suite 324 Frisc, Texas Office: Fax: smile@renewdentistry.cm PATIENT INFORMATION Patient Name: Birth Date: Age: Gender: SS #: Address: City: State: Zip: Hme Phne: Wrk: Cell: Emplyer: Hw did yu hear abut us?: Emergency Cntact Name: Relatinship: Phne: DENTAL INSURANCE INFORMATION Name f Insured: Insured s Birth Date: Subscriber ID #: SS #: Relatinship t patient: Insured s Emplyer Name: Insurance Cmpany: Grup Number: Phne: Insurance Claims Mailing Address: Please describe the main reasn fr yur appintment with Dr. Maxwell. (Hw lng has this issue been ging n & what ther past events apply?) Explain: Please rate yur smile. Dislike Satisfied When was yur last Dental Examinatin? Cleaning? X-Rays? Current Hme Care: Tth Brush: Manual r Electric Hw ften? Flss: Daily Occasinally Rarely Circle previus dental prcedures experienced: Whitening Take-hme trays/zm In-ffice Csmetic veneers/crwns Implants Orth/Invisalign Extractins
2 PLEASE RATE THE IMPORTANCE OF THE FOLLOWING GOALS. Optimal Preventative Care (practive apprach t underlying prblems, preventing issues befre they arise) Nt Imprtant Extremely Imprtant Explain: Optimal Restrative Care (remving ld metal fillings, cavity preventin prducts, prtecting dental wrk, Invisalign) Nt Imprtant Extremely Imprtant Explain: Csmetic Optins (whitening, prcelain veneers) Nt Imprtant Extremely Imprtant Explain: Please share yur individual dental expectatins. Explain: DO YOU HAVE ANY OF THE FOLLOWING? (Circle Yes r N) Disclred r dark teeth? Yes N Old unsightly crwn with black lines? Yes N Spaces between yur teeth? Yes N Crwded r crked teeth? Yes N Histry f rthdntic treatment? Yes N Any histry f gum disease? Yes N Red, swllen, bleeding r receding gums? Yes N Chipped, thin, r wrn dwn teeth? Yes N Clenching r grinding yur teeth? Yes N TMJ, jaw, r muscle sreness? Yes N D yu have a night guard/nti? Yes N Cver yur muth when yu smile? Yes N Anxiety with dental wrk? Yes N MEDICAL HISTORY Are yu currently under the care f a physician? Yes N Please list belw: Physicians Name: Office Number: Address: City: State: Zip: Cnditin being treated: Physicians Name: Office Number: Address: City: State: Zip: Cnditin being treated: PREFERRED PHARMACY: Pharmacy Name: Phne Number: Fax Number: Address: City: State: Zip: D yu smke r use tbacc prducts? Yes N If yes please, Hw ften? Hw much?
3 HAVE YOU EXPERIENCED TROUBLE WITH (check all that apply): Thyrid Hair Lss Gag Reflex Md Swings Jint Replacement Irritability Truble Swallwing Fggy Thinking Herpes Anxiety Shingles Fatigue HIV/Aids Elevated Chlesterl Hepatitis Heart Palpitatins Appendix High Bld Pressure Gall Bladder Lw Bld Pressure Bad Breath Heart Murmur Ulcers/Blisters Heart Attack Headaches/Migraines Swllen Extremities Kidney prblems Chest Pain/Pressure Dry Muth Abnrmal Bleeding Diabetes Anemia Epilepsy/Seizures Rheumatic Fever Strke Cngenital Heart Defect Arthritis Dwn Syndrme Fatigue Pacemaker/Artificial Valve Dizzy Spells Mitral Valve Prlapse Swllen Lymph ndes Brnchitis Pr Memry Pneumnia Asthma Lung Disease Bld Transfusin Depressin Cancer Chem Treatments Latex Allergy Metal Allergy Ehlers-Danls Syndrme Penicillin Allergy Sulfa Drug Allergy Cdeine Allergy Alchlism Drug Abuse Heart disease HPV Hemphilia Aspirin Allergy Fd Allergies (please list belw) Sinus Truble Other: Please List Any Knwn Allergies and/r Drug Allergies: WOMEN ONLY Is there a chance yu may be pregnant? Yes N Are yu currently nursing? Yes N Are yu taking any ral cntraceptives? Yes N Have yu had a Hysterectmy? Yes N LIST MEDICATIONS (Rx & Over-the-cunter, Dsage, Frequency): PLEASE LIST ALL SURGERIES/INJURIES & DATE: T the best f my knwledge, the questins n this frm have been cmpleted accurately. I understand that prviding incrrect infrmatin can be dangerus t my (r Patient s) health. It is my respnsibility t infrm the dental ffice f any changes in medical status. SIGNATURE OF PATIENT, PARENT, OR LEGAL GUARDIAN DATE
4 Dental Treatment & Infrmatin Acceptance Frm Please initial each sectin. Health Infrmatin I agree t disclse ALL previus illnesses, medicatins; medical, dental and family histry. Any undisclsed infrmatin r missins culd have a negative effect n my dental and ral health. I have been infrmed there are ral-systemic links that can affect my verall wellness. DRUGS, LATEX and MEDICATIONS I understand that antibitics and ther medicatins can cause allergic reactins and/r anaphylaxis, which is ptentially a life-threatening cnditin that can interfere with nrmal breathing. Latex allergies can cause rashes and itching. Epinephrine, which is used in sme dental injectins, increases heartbeat, and depending n my health status may be dangerus. Please, disclse any infrmatin n ur health histry frms pertaining t any knwn drug r latex allergies. DENTAL TREATMENT I authrize Renew Family Dentistry t take radigraphs, study mdels, phtgraphs, and any ther diagnstic aids deemed apprpriate t my ral health needs apprpriate t my ral health needs. I als authrize Dr. Jshua Maxwell t prescribe any frms f medicatin, and perfrm any therapy that may be indicated and agreed upn. It is pssible that a tth may require enddntic treatment (rt canal), even after a filling r a crwn is dne depending n the depth f existing restratins r decay present. This is nt always predictable frm radigraphs alne. I als understand that if my teeth are sensitive after treatment, I must cntact the ffice fr an appintment t address my cncerns. PORCELAIN CROWNS / VENEERS / BONDING & COSMETIC FILLINGS Once a crwn, veneer, bnding r filling is placed, I understand the clr cannt be changed withut a remake. I have been cunseled, infrmed and educated n hw imprtant it is t maintain a healthy balanced dental regimen achieved by cmplying with hygiene and dental treatment plans set ut by Dr. Maxwell. I understand that many factrs cntribute t my ral health: stress, clenching, grinding, acidity, diet and genetics. I am aware that mst peple grind their teeth subcnsciusly, which is damaging t the teeth and can break teeth r dental restratins. I have been infrmed abut the need t wear an cclusal guard fr prtectin, and a bite check is suggested.
5 PHOTOGRAPHY RELEASE In rder t diagnse; I understand that phtgraphs, x-rays and vides will be taken and used as recrd fr my case. HYGIENE THERAPY I understand if that upn diagnsis f peridntal disease, I n lnger fall under the categry f a rutine r healthy muth dental cleaning. The treatment is then categrized under the peridntal dental prcedure cdes which require additinal services than rutine r healthy muth cleanings. Bleeding gums and family histry will cntribute t this diagnsis. APPOINTMENT TIMES & EMERGENCY CARE I understand that patients are seen by appintment nly. I grant permissin fr cntacting me via telephne (wrk, hme r cell), r text t discuss matters related t my treatment, accunting, r dental appintments. It is ur philsphy t be available t all patients and we ask fr yur cperatin t nly use the emergency cntact line fr true emergencies, such as, a brken tth r severe dental infectin causing swelling and pain. COURTESY REMINDERS As a curtesy, I understand that Renew Family Dentistry prvides a 48 hurs reminder Text and fr all scheduled appintments. I accept that it is my respnsibility t reply any cnfirmatin Text and/r s within 24 hurs (1 business day) f my scheduled appintment. I als reserve the right t Opt Out f Text and/r reminders, if I chse t d s I understand that a curtesy reminder call will be given hurs befre my scheduled appintment. I have received and understand the dental treatment and acceptance frm f Renew Family Dentistry. I als understand that it is my respnsibility t infrm the dental ffice f any changes in medical status. SIGNATURE OF PATIENT, PARENT, OR LEGAL GUARDIAN DATE
6 LIMITATION OF INSURANCE COVERAGE and PAYMENT We realize hw cmplex and cnfusing dental insurance can be. We wuld like t highlight a cmmn miscnceptin- dental insurance was nt designed t pay fr all dental care. Mst cntracts have limitatins and/r varius degrees f c-payment. The benefits yu receive are based n the cntract between yu r yur emplyer and the dental insurance cmpany, nt ur ffice. Sme services yu may need r want may nt be cvered by yur insurance benefit plan. The treatment plans are based n an estimate prvided by yur insurance cmpany and are subject their review. There are n guarantees f cverage. Our gal is t help yu achieve and maintain ptimal dental care and we will nt cmprmise yur care based n restraints f an insurance cmpany. As a curtesy, Renew Family Dentistry will file all claims based n yur PPO dental insurance plan. All Applicable deductibles, c-insurance amunts, and nn-cvered services amunts are due at the time service is rendered. Yu will be required t pay fr yur visit in full at the time f service if yu are unable t prvide the current insurance infrmatin befre yur scheduled appintment. All estimated payments are cllected befre yu are seen by the dctr and any adjustments that need t be made can be made at the end f yur visit, and any final bill and/r credit will be issued nce payment frm yur insurance cmpany has been received. Cash, persnal checks, Master Card, Visa, Discver, and Care Credit are all acceptable frms f payment in ur ffice. Picture ID is required in cnjunctin with all frms f payment except cash. We d nt ffer in-huse financing; hwever, we have partnered with Care Credit which ffers several shrt term n-interest and lng term payment plans with minimal interest. Yu can apply fr Care Credit in ur ffice with the assistance f a staff member r nline at I have received and understand the financial plicy f Renew Family Dentistry; I als hereby give Renew Family Dentistry permissin t file claims with my insurance cmpany n my behalf. SIGNATURE OF PATIENT, PARENT, OR LEGAL GUARDIAN DATE
7 Missed Appintment and Late Cancellatin Plicy A missed dental appintment presents prblems fr us bth. Fr yu, a missed dental appintment causes a delay in treatment that was recmmended t help imprve yur dental health. Fr ur ffice, a missed dental appintment prevents us frm scheduling anther patient that culd benefit frm treatment. We schedule individual time with each patien t allw us t deliver the quality and persnal care that every patient deserves. Our ffice plicy is that we charge $25 t $100 fr a missed appintment, late cancellatin, r fr failed appintments. The charge is based n the length reserved fr yur appintment. We understand that things happen and schedules d change. We ask that yu prvide us with at least 24-hur ntice fr any appintment changes. Failure t prvide at least a 24-hur ntice fr changed appintments will result in a fee. We value and appreciate yu as a patient and lk frward t seeing yu fr future appintments. Thank yu, Renew Family Dentistry Jshua F. Maxwell DDS, FAGD, FICOI, PC Patient Name (Print): Print Parent/Guardian Name: Patient/Guardian Signature: Date:
8 Thank yu fr cmpleting yur paperwrk
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