Thank you for visiting Main Street Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form.
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- Jeffery Mills
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1 Thank yu fr visiting Main Street Dental Care. We want yur visit t be pleasant and cmfrtable. Please help us by cmpleting this frm. Patient Infrmatin Name LAST FIRST MIDDLE INITIAL NICKNAME Address STREET CITY STATE ZIP CODE Emplyer Driver s License Birth Date Height Weight Phne: Hme ( ) Scial Security # Wrk ( ) May we cntact yu at wrk? Yes N Mbile ( ) Male Female address Married Single Dependant/Child Please circle yur preferred cntact methd fr appintment cnfirmatins: Phne call Text Please circle yur preferred cntact methd fr recall appintments: Phne call Text Pstcard Emergency Name and Phne Number: ( ) Insurance (cmplete bx nly if yu have dental insurance) Primary Dental Carrier Subscriber Name Scial Security # DOB Emplyer Insurance C. Insurance C Phne Grup # Relatin t Patient I hereby authrize payment directly t the dental ffice f the grup insurance benefits therwise payable t me. I understand that I am respnsible fr all cst and dental treatment. SIGNATURE DATE I understand that I am respnsible fr all csts fr dental treatment. I hereby authrize Main Street Dental Care t administer such medicatins and perfrm such diagnstic and therapeutic prcedures as may be necessary fr prper dental care. The infrmatin n this page and the medical histry is crrect t the best f my knwledge. SIGNATURE DATE If Patient is under 18: Respnsible Party: Relatin t Patient Address STREET CITY STATE ZIP CODE Phne _( )
2 Medical Histry and Infrmatin Yur current health is: Gd Fair Pr Are yu currently in pain? Yes N Have yu ever had gum treatment Yes N D yur gums bleed? Yes N Are yu under stress (new jb, mving, relatinships)? Yes N Hw many times d yu: flss/week? brush/day? Are yur teeth sensitive t ht, cld r anything else? Yes N Have yu lst any teeth? Yes N D yu take any bne density medicatins? Yes N D yu suffer frm apthus ulcers r fever blisters? Yes N If s we have a therapeutic laser prcedure that can alleviate the pain and future reccurrence f these lesins at the treated sites. Please list yur persnal physician and phne number: Please list any medical specialist(s) and phne number(s) whse care yu are presently under: Please list any surgical prcedures yu have had in the last 5 years: Have yu had any metal rds, pins, prsthetics, screws r implants placed? Yes N Cnditins Please check all that apply: Abnrmal Bleeding Alchl Abuse Allergies Anemia Angina Pectris Arthritis Artificial Heart Valve Asthma Birth Cntrl Pills Bld Transfusin Cancer Chemtherapy Clitis Cngenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Facial Surgery Facial Trauma Fainting Spells Fever Blisters Frequent Headaches Glaucma HIV+/AIDS Heart Attack Heart Surgery Heart Murmur Hemphilia Hepatitis A Hepatitis B Hepatitis C High Bld Pressure Jint Replacement Kidney Prblems Liver Disease Lw Bld Pressure Mitral Valve Prlapse Pace Maker Psychiatric Prblems Radiatin Therapy Rheumatic Fever Seizures STD s Shingles Sickle Cell Disease Sinus Prblems Strke TMJ Disrders TMJ Pain TMJ Clicking/Ppping Thyrid Prblems Tuberculsis Vertig Ulcers Allergies Aspirin Cdeine Sedatives Dental Anesthetics Erythrmycin Latex Metals Penicillin Sulfa Tetracycline Other Allergy Yes N D yu smke? D yu use tbacc? D yu usually pre-med befre yur dental visits? If Female: Are yu pregnant? Are yu nursing? D yu suffer frm any ther cnditins/disrders that are nt listed abve? Please list any medicatins that yu are currently taking: I attest that the infrmatin given is true and accurate t the best f my knwledge. Signature Date
3 Other Infrmatin Hw did yu hear abut us? Please circle ne: Mailer Sign/Drive by Internet/Ggle Internet/Yah Yellw Pages Phnebk AT&T Phnebk Pelican Pages Phnebk Friend/Referral Other What is the reasn fr tday s visit? Wuld yu be interested in the use f Nitrus Oxide t make yur visits easier? Why did yu leave yur last dentist? What did yu like mst abut yur last dentist? Have yu had any unfavrable dental experiences? Yes N When was yur last dental cleaning? When was yur last dental x-ray? When was yur last dental visit? Hw can we accmmdate yu better during yur dental visit? D yu lve yur smile? Here at Main Street Dental Care, we ffer a wide variety f services t enhance and keep yur smile beautiful. Please circle any services belw that yu wuld like ur friendly staff t discuss with yu during yur visit. In Office Whitening Veneers Implants/Implant Crwns Take Hme Whitening Crwn and Bridge Smile Makever 6 Mnth Braces (Orthdntics) Night/Sprt Guard Btx Invisalign Sealants Dermal Fillers Partials/Dentures Bnding Btx fr TMJ and Pain Management Treatment Authrizatin Frm I authrize and give cnsent t perfrm dental services agreed between dctr and patient are/r parent r guardian t be necessary r advisable including the use f lcal anesthesia and ther medicatins as indicated. I certify t the abve statements regarding my medical cnditin. Payment fr all treatment and services rendered are my respnsibility. Patient s Signature Date Parent/Guardian Signature Date
4 Main Street Dental Care At Main Street Dental Care, we believe that yu deserve the best care. That s why we always present yu with the best dental slutin pssible t treat yur persnal situatin. Each year we prvide utstanding dental care t hundreds f patients. Sme have dental benefits but sme d nt. If yu have dental benefits, cngratulatins! Yu are very frtunate. Here are sme imprtant things yu shuld knw... Yur dental benefits are based n a cntract made between yur emplyer and an insurance cmpany. If yu have any questins regarding yur dental benefits please cntact yur emplyer r insurance cmpany directly. Dental benefit plans will never pay fr cmpletin f yur dental care. It is nly meant t assist yu. We currently accept all private care insurance plans (plans that d nt require yu t select a dentist frm a list r require ur ffice t accept a reduced fee fr service). This means that we wrk with literally thusands f cmpanies. Althugh we can maintain cmputerized histries f payment by a given cmpany, they d change; therefre it is impssible t give yu a guaranteed qute at the time f service. We estimate yur prtin based n the mst up-t-date infrmatin we have, but it is ONLY AN ESTIMATE. If yu wuld like t knw yur exact insurance benefit, we will be happy t file a pretreatment authrizatin with yur insurance cmpany prir t treatment. This des delay treatment but will give yu the exact ut f pcket figures yu may require. Many peple receive ntificatin frm their insurance cmpany that dental fees are abve usual and custmary. An insurance cmpany determines their reimbursement level by surveying a gegraphical area, calculating the average fee, and then determines that 80% f the average fee is custmary. Included in this survey are discunted dental clinics and managed care facilities, which have severely reduced dental fees that bring dwn the average. Any dctr in private practice will have fees that insurance cmpanies define as higher than usual and custmary. We bill yur insurance as a curtesy. If insurance des nt pay within 90 days, Main Street Dental Care reserves the right t request payment in full fr services frm yu and let yu cllect the insurance funds that are due t yu. This is rare but it is imprtant that yu recgnize that the insurance yu have is a legal cntract between YOU and yur insurance cmpany. Our ffice is nt, and cannt be a part f that legal cntract. Ultimately, yu are respnsible fr all charges incurred in ur ffice. Main Street Dental Care des require payment in full fr yur prtin at the time f service. We accept MasterCard, Visa, Discver, cash and checks (fr existing patients with established payment histry). We d nt accept checks fr ver $ fr any patient. If yu are in need f an extended finance ptin, we als wrk with Care Credit, wh ffers a twelve mnth same as cash r lnger terms with an interest bearing revlving charge designed t meet yur treatment plan needs n apprved credit. Just ask ne f the patient services staff fr an applicatin. A $25.00 fee will be added t yur accunt balance fr any returned checks due t insufficient funds, as well as the amunt f the returned check. Office Refund Plicy If yur accunt results in a credit due t write ffs within tw years time, yu are nt eligible fr a refund check. Our ffice will hwever allw yu t use that credit tward future wrk. Brken Appintments: A specific amunt f time is reserved especially fr yu and we strngly encurage all patients t keep their appintments. If yu must change yur appintment, we require at least 24 hur ntice t avid a $35/hur cancellatin fee (emergencies are an exceptin). After Hurs/Weekend Emergencies: In the event f an emergency after regular business hurs a $55 emergency fee will be charged fr established patients in additin t the necessary treatment fees. Patients wh are nt established in the practice will be charged $125 after hurs emergency fee. We welcme yu t ur family and lk frward t helping yu get the healthy, beautiful smile that yu have always wanted. If there is anything we can d t make yur visits here mre pleasant, please dn t hesitate t ask ne f ur staff members. Print: Sign:
5 GONSENT FOR DENTAL TREATMENT AND ACKNOWLEDGMENT OF RECEIPT OF INFORMATION State law requires us t btain yur cnsent fr dental treatment. Please ask us abut anything yu d nt understand. We are ready t answer any f yur questins r explain anything yu d nt understand. There are risks assciated with any dental treatment. This includes the administratin f any lcal r general anesthetic agent, analgesic agent(s) t prduce cnscius sedatin and/r premedicatin prir t dental care being rendered. Sme f these risks/cmplicatins are, but are nt limited t the fllwing: Infectin Bleeding Failure f wund t heal Lss f teeth Lss f bne lnstrument breakage Bacterial endcarditis Breakage f rt(s) and retained rt fragments Swallwing and/r aspiratin f bjects Failure f treatment accmplish main purpse Trismus (jaw pain r difficulty pening muth) Opening between muth and sinus r muth and nse Injuries t adjacenteeth and/r hard sft tissue Dry scket Incmplete remval qf tth Injury t adjacent structures Allergic reactin t drugs Tth r fragment in maxillary sinus Death (in rare instances) Parasthesia r numbness f tngue and/r muth, and/r face Fracture f mandible (lwer jaw) r maxilla (upper jaw) Slugh (unanticipated lss f hard and/r sft tissue) Additinal ral surgery, hspitalizatin and/r further treatment may be required in the event f any cmplicatin(s). ACKNOWLEDGMENT I acknwledge that I have read this cnsent frm, r that it has been read t me, and that I understand the infrmatin cntained n this cnsent frm. I was given an adequate pprtunity t ask any questins and all questins were answered t my satisfactin. I hereby authrize and direct the dentist and/r assciates, hygienist, assistants f their chice t perfrm the diagnstic, surgical r dental treatment. This cnsent frm will remain valid unless revked by me in writing, Signature f patient r guardian DATE
6 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Prtability & Accuntability Act f 1996 ( HIPPA ), I have certain rights t privacy regarding my prtected health infrmatin. I understand that this infrmatin can and will be used t: Cnduct, plan, and direct my treatment and fllw-up amng the multiple healthcare prviders wh may be invlved in that treatment directly and indirectly. Obtain payment frm third-party payers. Cnduct nrmal healthcare peratins such as quality assessments and physician certificatins. I have received, read, and understand yur Ntice f Privacy Practices cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I understand that this rganizatin had the right t change its Ntice f Privacy Practices frm time t time and that I may cntact this rganizatin at any time at the address abve t btain a current cpy f the Ntice f Privacy Practices. I understand that I may request in writing that yu restrict hw my private infrmatin is used r disclsed t carry ut treatment, payment, r healthcare peratins. I als understand yu are nt required t agree t my requested restrictins, but if yu d agree then yu are bund t abide by such restrictins. Patient Name: Relatinship t Patient: Signature: Date: Please list any individual(s) that yu give permissin t have access t recrds (medical & financial): OFFICE USE ONLY I attempted t btain the patients signature in acknwledgement n this Ntice f Privacy Practices, but was unable t d s as dcumented belw: Date: Initials: Reasn:
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