David Palmieri, D.M.D., M.S., LTD., Frank R. Portell D.M.D.,M.S. & Nathan Schoenly, D.D.S. PATIENT REGISTRATION Please Check: Mr. Ms. Mrs. Dr. Fr. Sr. Hon. OTHER: Your Name (first name) (middle int.) (last name) Address City State Zip Phone Numbers Home: ( ) Business: ( ) Mobile: ( ) Email: Date of Birth Female Male Social Security Number Spouse s Name General Dentist Referred By First Name Last Name First Name Last Name Physician: Physician Phone: ( ) First Name Last Name Employer Occupation If patient is a minor, who is legally responsible? (first name) (last name) SS# DOB In case of emergency, whom should we contact? Phone: ( ) Are you a former patient in this practice? Yes No If yes, which office and how long ago? INSURANCE INFORMATION Name of insurance company Phone ( ) Insurance Address: City: State: Zip: Subscriber s Name: First Name Last Name Subscribers SS# Date of Birth of subscriber Patients Relationship to subscriber: Subscribers Employer: Insurance ID # Group# I hereby authorize Dominion Endodontics to release dental information to my insurance company in order for claims to be processed. I have received the financial agreement from Dominion Endodontics. Patient /Guardian Signature Date
David Palmieri, D.M.D, M.S., Ltd., Frank R. Portell D.M.D.,M.S. & Nathan Schoenly D.D.S. MEDICAL HISTORY Are you being treated by a physician?... If so, for what condition? What drug or medications are you taking? Have you had major or minor surgery in the past five years?... Have you ever fainted or had seizures?... Has your physician recommended premedication for dental appointments?... Are you currently taking or have previously taken bisphosphonate medications such as Actonel,Fosomax or Boniva within the past twelve years?... Do you have or have you had any of the following? YES NO YES NO Chest pain... Sinus problem... Heart murmur... Prosthetic joints... Mitral valve prolapse... Cancer/Radiation TX... Rheumatic fever... Diabetes... Cardiac pacemaker... Asthma, T.B.... High blood pressure... Thyroid imbalance... Blood disorders(anemia etc.)... Venereal disease... Abnormal bleeding... Stomach ulcers... Hepatitis or jaundice... Severe anxiety... Positive HIV test... Psychiatric therapy... Glaucoma... Arthritis... Kidney disease... Please list any allergies Have you had any ill effects from: Local anesthetics (Novocain, Xylocaine etc)?... Aspirin or Codeine?... Penicillin, erythromycin, or other antibiotics?... Any other drugs? FOR WOMEN ONLY: YES NO YES NO Are you taking birth control pills?... Are you pregnant?... Are you nursing?... DO YOU HAVE ANY OTHER MEDICAL PROBLEMS WHICH SHOULD BE NOTED FOR ANY REASONS?... YES YES NO NO Signature: Date:
Patient Name (Print)
Financial Policy You are financially responsible for dental services you receive. Please review our policies below and sign at the end to indicate your agreement to these terms. A. APPOINTMENTS 1. Copayments: Copayments for dental visits are due at the time of service. If you are unable to make your copayment at the time of service, Dominion Endodontics: David Palmieri DMD, Ltd reserves the right to reschedule your appointment until a time that you are able to make your copayment and or payment. Payment for any outstanding balance is due at your appointment. 2. Procedure Prepayment: Dominion Endodontics: David Palmieri DMD, Ltd collects your payment for a procedure at the time when the procedure is scheduled. Your prepayment is based on an estimate of your expected financial responsibility. This is an estimate only. You are responsible for any unpaid balance after your insurance (if applicable) has been billed. We reserve the right to reschedule your procedure until prepayment and or Payment has been made. 3. Appointment Cancellation: Dominion Endodontics: David Palmieri DMD, Ltd does not charge for cancellation fee but reserves the right to pre-collect 50% of your copayment or payment prior to rescheduling your appointment. If there is no payment due from you because you are covered at 100% by your insurance, Dominion Endodontics: David Palmieri, DMD, Ltd reserves the right to collect at least 20% of the cost of your procedure. 4. Missed Appointments and Late Arrivals: Dominion Endodontics: David Palmieri DMD, Ltd does not charge for missed appointments and late arrival but reserves the right to pre collect 50% of your copayment or payment prior to rescheduling your appointment. If there is no payment due from you because you are covered at 100% by your insurance, Dominion Endodontics: David Palmieri, DMD, Ltd reserves the right to collect at least 20% of the cost of your procedure. If you are more than 15 minutes late, we may reschedule your appointment. B. INSURANCE PAYMENTS 1. Financial Responsibility: Your Insurance policy is a contract between you and your insurance carrier. You are ultimately responsible for payment-in- full for all dental services provided to you. Any charges not paid by your insurer will be your responsibility, except as limited by our contract (if any) with your insurance carrier. 2. Coverage Changes and Timely Submission: It is your responsibility to inform us in a timely manner of any changes to your billing or insurance information. There is a time limit within which Dominion Endodontic: David Palmieri, DMD, Ltd must submit a claim on your behalf to your insurer. If Dominion Endodontic: David Palmieri, DMD, Ltd is unable to submit your claim within this period because we have not been supplied with your correct insurance information, you will be responsible for the charges.
C. BENEFITS AND AUTHORIZATION 1. Insurance Plan Participation: We participate in many but not all insurance plans. It is your responsibility to contact your insurance company to verify that your assigned dentist participates in your plan. Out of network charges may have higher deductibles and copayments. 2. Non-Covered Services: Dominion Endodontics: David Palmieri, DMD, Ltd may provide services that insurance plans exclude. If insured, it is ultimately your responsibility to ensure that services provided to you are covered benefits by your insurer. Dominion Endodontics: David Palmieri, DMD, Ltd. As a courtesy to our patients, makes a good faith effort to determine if services we order are covered by your insurance plan. 3. Reassignment of Balances: If your insurance company does not pay within a reasonable time, we may transfer the balance to your sole responsibility. Please follow up with your insurance carrier to resolve non-payment issues. Balances are due within 30 days of receiving a statement. 4. Collection of Unpaid Accounts: If you have an outstanding balance over 120 days old and have failed to make payment arrangements or become delinquent on an existing payment plan, we may turn your balance over to a collection agency and/or an attorney, which may result in reporting to credit bureaus and/or legal action. Dominion Endodontics David Palmieri, DMD, Ltd. reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You agree to pay Dominion Endodontics: David Palmieri, DMD, Ltd. for any expenses we incur to collect on your account, including reasonable attorneys` fees and collection costs. 5. Returned Checks: Returned checks will be subject to a $35 returned check fee. 6. Refunds for Overpayment or Prepayment: Refunds for overpayment or prepayment on cancelled procedures are made only after there has been full insurance reimbursement for all dental services on your account. 7. Statements: Charges shown by statement are agreed to be correct and reasonable unless protested in writing within thirty (30) days of the billing dates. 8. Over the Phone Payment: Dominion Endodontics: David Palmieri, DMD, Ltd can take a payment over the phone, as long as the following information is provided: CVV code/security code, Name as it appears on the card and Billing zip code. D. SOCIAL SECURITY NUMBER Dominion Endodontics: David Palmieri DMD, Ltd requires that ALL patients must provide their SSN and the primary subscriber s SSN on the Patient Registration Form. The SSN is used for billing and/or to verify payment and/or coverage from your insurance company. The SSN is also required for uninsured patients. Patients who wish not to provide this information will be asked to prepay the full amount for dental services before their scheduled appointment. All patient registration forms are shredded in our office at the end of the day to protect your information. All information entered in our computer system is protected by safe software that utilized encryption and individual passwords for access.
E. MINOR PATIENTS Dominion Endodontics: David Palmieri DMD, Ltd is legally required to mandate that any patient who is below the age of 18 must be accompanied by an adult. The adult that accompanies the child will be held financially responsible for any dental service that is provided to the minor patient. This policy strictly applies regardless of marital and guardianship statuses. As the adult accompanying the minor, you agree to financially cover all services provided to the child. You also agree to provide your billing information, SSN, and contact information on the Patient Registration Forms. F. CHANGE IN ADDRESS If the current billing address we have on file changes due to the patient relocating, it is ultimately the patient s responsibility to notify Dominion Endodontics: David Palmieri DMD, Ltd. This will avoid miscommunication between the patient and the billing department. The billing department will only correspond with the address provided by the patient and therefore, will not waive any previously sent statements/notices in the event the patient fails to notify the office about a change of address. G. PAYMENT PLANS Dominion Endodontics: David Palmieri DMD, Ltd offers payment plans in the event that a patient cannot pay the full amount due at the time of service. The Payment Plan Installment will be at the Office Manager s discretion. For Payment Plan Agreements, you will provide a credit card for Dominion Endodontics: David Palmieri DMD, Ltd to keep on file. Debit Cards will not be accepted for any payment plans. It is ultimately your responsibility to provide a credit card with sufficient funds. Patients should check that funds for the procedure are available prior to providing a credit card number. In the event that you do not have a credit card, Dominion Endodontics: David Palmieri DMD, Ltd encourages you to apply for the Dental Credit Card: Care Credit. I have read and understand the financial policy of Dominion Endodontics: David Palmieri, DMD, Ltd. and I agree to abide by its terms. I hereby assign all dental benefits and authorize my insurance carrier(s) to issue payment directly to Dominion Endodontics: David Palmieri, DMD, Ltd. I understand that I am financially responsible for all services I receive from Dominion Endodontics: David Palmieri, DMD, Ltd. This financial policy is binding upon you and your estate, executers and/or administrators, if applicable. Please circle the method of payment: Cash Check Credit Card: Visa, Mastercard, AMEX, Discover Dental Credit Card: CareCredit Patient Name (Print) Signature Date Responsible Party/Guarantor (Print) Signature Date
INFORMED CONSENT AND TREATMENT AUTHORIZATION 1) The purpose of ROOT CANAL THERAPY is to retain teeth that would otherwise have to be extracted. Although it has a very high degree of clinical success, it is still a biological procedure so it cannot be guaranteed. Occasionally a tooth which has had root canal therapy may require retreatment, surgery, or even extraction. 2) Treatment may require multiple visits. It is important that you maintain scheduled appointments or the infection can reoccur. 3) In most cases, there is only mild discomfort following each treatment. This is usually controlled with ASPIRIN, TYLENOL, IBUPROFEN or other prescribed medication. 4) Accurate and complete disclosure of medical information is necessary for a proper diagnosis. This is necessary to prevent complications during your treatment. 5) Possible complications with root canal therapy include, but not limited to; a) Continued infection requiring endodontic (root canal) surgery or extraction of the tooth. b) Calcified canals or canals blocked by broken instruments requiring endodontic surgery or extraction of the tooth. c) Pain, requiring the use of medication d) Side effects and reactions to medication. e) Fractures (breaking) of the root or crown of the tooth during or after treatment f) Tenderness of the tooth following treatment due to possible complications with the root canal treatment, gum disease, physical stress from chewing or the degree of healing your body exhibits. It is recommended that all posterior teeth be crowned following ROOT CANAL THERAPY. If your tooth already has a crown, often the crown can be repaired after endodontic treatment. Porcelain crowns are subject to breakage. Since ONLY THE ROOT CANAL TREATMENT IS TO BE PERFORMED IN THIS PRACTICE, PLEASE MAKE AN APPOINTMENT WITH YOUR REGULAR DENTIST FOR A CROWN OR RESTORATION IN ORDER TO AVOID TOOTH FRACTURE. 6) Other treatment choices include no treatment, waiting for more definite development of symptoms, and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection to other areas. 7) I also acknowledge full responsibility of the payment of such services and agree to pay for them, in full, at or before completion of the services, unless other specific arrangements are made with the front desk. 8) I have read and understand the above, and hereby consent to treatment 9) I,, authorize David Palmieri, DMD, MS, Ltd., Frank Portell, DMD, Nathan Schoenly DDS to take x-rays, to administer such anesthetics and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of the patient listed above. Signature: Relationship: Date: