Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.

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Transcription:

Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation is needed upon which we can base recommendations for your dental health. Therefore, we will complete a thorough oral health and cosmetic dental examination during your initial appointment. Preventive dentistry is the most important service we have to offer you. We will show you how to control your own dental health and maintain your beautiful smile. Preventive examinations on a regularly scheduled basis will give you the maximum opportunity for long-term dental health. Good communication is essential to forming a satisfactory relationship. If you ever have a concern about any treatment, fee, or service, please feel free to discuss it immediately and openly with any of us. We would really appreciate this. We welcome your comments and suggestions, and want to do everything we can to make your visit a pleasant experience. Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you. Sincerely, Drs. Carol and Scott Lybrook

551 Kokopelli Blvd. Kokopelli Professional Plaza Fruita, CO 81521 970-858-9511 www.lybrookdental.com WELCOME : Legal Name: Male Female I prefer to be called Married Single Divorced Widowed Separated Birth date: Age: Home Address: City: Zip: Home#: Work#: Cell#: Social Security# Driver s License# e-mail: May we confirm your appointments using your e-mail address? Yes No Employer: How long at job Address: Whom may we thank for referring you? Parent or Spouse Information His/Her Name: Home #: Work#: Soc. Sec. #: Birthdate: Employer: Person Responsible for Account: Home#: Work#: Cell #: Soc. Sec. # Drivers License#: Dental History Previous/Present Dentist: Last Visit Why have you come to the dentist today? Are you currently in pain? Yes No Have you ever had a serious/difficult problem associated with any previous dental work? Yes No Do you or have you ever-experienced pain/discomfort in your jaw joint (TMJ, TMD)? Yes No Your current Dental Health is: Good Fair Poor Do you like your smile? Yes No Do your gums ever bleed? Yes No How many times a week do you floss: How many times a day do you brush? Type of bristles? Hard Medium Soft

Medical History Do you have a personal Physician? Yes No Physician s Name: Phone# Last Visit : In case of emergency, whom should we contact? His/Her Name? Relationship: Home#: Work#: Cell#: Your current physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Are you taking any prescription/over the counter drugs? Yes No Please list each one: For Women only: Are you taking birth control pills? Yes No Are you pregnant? Yes No Week #: Are you nursing? Yes No Please list any medical condition(s) you now have or have ever had: Are you allergic to any of the following: Aspirin Erythromycin Codeine Latex Gloves Penicillin Jewelry/Metal Dental Anesthetics Tetracycline Other (explain) Please list any drugs you are allergic to: Please CIRCLE all of the medical problems you currently have or have ever had: Artificial Joints Abnormal Bleeding Fever Blisters/Herpes Shingles Blood Transfusions Anemia Glaucoma Sinus Problems Cong. Heart Defect Asthma Heart Attack Stroke Heart Murmur Arthritis Heart Trouble Ulcers Heart Pacemaker Cancer Hemophilia Venereal Disease Mitral Valve Prolapse Chemotherapy High/Low Blood Pressure Diabetes Rheumatic Fever Colitis Hospitalized for any reason Gluten Intolerance Heart Surgery Difficulty Breathing Kidney Problems Osteoporosis Hepatitis Drug/Alcohol Abuse Psychiatric Problems Thyroid HIV/AIDS Emphysema Radiation Treatment Acid Reflux Tuberculosis (TB) Epilepsy Severe/Frequent Headaches I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I any need during diagnosis and treatment with my informed consent. SIGNATURE: *PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. Doctor s Comments: I verbally reviewed the medical/dental information above with the patient named herein. Comments Signature

GENERAL CONSENT Thank you for choosing our office for your dental care. We will work with you to help you achieve excellent oral health. While recognizing the benefits of a pleasing smile and teeth that function well, you should be aware that dental treatment, like treatment of any other part of the body, has some inherent risks. These are seldom great enough to offset the benefits of treatment, but should be considered when making treatment decisions. Benefits of dental treatment can include: relief of pain, the ability to chew properly, and the confidence and social interaction that a pleasing smile can bring. Nonetheless, there are some common risks associated with virtually any dental procedure, including: 1. Drug or chemical reaction. Dental materials and medications may trigger 2. allergic or sensitivity reactions. 3. Long-term numbness (paresthesia). Local anesthetic, or is administration, 4. while almost always adequate to allow comfortable care, can result in 5. transient, or in rare instances, permanent numbness. 6. Muscle or joint tenderness. Holding one s mouth open can result in 7. muscle or Jaw joint tenderness, or in a predisposed patient, precipitate a 8. TMJ disorder. 9. Sensitivity in teeth or gums, infection or bleeding. 10. Swallowing or inhaling small objects. While we follow procedural guidelines that most often lead to a clinical success, just like in any other pursuit in health care, not everything turns out the way it is planned. We will do our best to assure that it does. Please feel free to ask questions in regard to all dental procedures that are recommended to you. I have read and understand the statement on this page: Patient s Signature Parent s Signature (if minor patient) 551 Kokopelli Blvd. Kokopelli Professional Plaza Fruita, CO 81521 970-858-9511 www.lybrookdental.com

Lybrook Dental Center Financial Policy We strongly feel that all patients deserve from us the finest dental care that we can provide. You will benefit from the high standards we have set for delivering the utmost quality of dental treatment available. We also feel that when financial arrangements are discussed and agreed upon, everyone benefits. Accordingly, we have prepared this information to acquaint you with our financial policy. PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. Please indicate below the method of payment that you will use to pay for the dental treatment. Payment Options: You can choose from: Cash or Check MasterCard, American Express, Discover Card or Visa Extended Payment Options: NO INTEREST Payment Plan from Care Credit (6 months) *Allows you to make payments over time with NO INTEREST, if paid on time and in full *Convenient, low monthly payment *No annual fees or pre-payment penalties Dental Insurance: Our office will do everything possible make the most of your dental insurance benefit. We do accept insurance benefits as partial payment for treatment along with your payment of the ESTIMATED patient portion cost. You are responsible for ALL fees and charges for our account. All insurance plans are different and may have limitations. These may include but are not limited to waiting periods, missing tooth clause, downgrade on services, exceptions and limitations of your specific plan for which we cannot be held responsible. Any insurance portion that has not been paid after 90 days will be billed to the patient. Dental Insurance Information: Employee/Policy Holder Name: DOB: Employer: Group Number: Primary Dental Insurance Carrier: ID Number: Insurance Carrier Phone Number: Please let us know if you have any questions or concerns. We are here to help you in any way we can. I have read the Lybrook Dental Center Financial Policy and I understand and agree to this policy. Patient, Parent or Guardian Signature

Lybrook Dental Center Missed Appointment Policy At Lybrook Dental Center, we are committed to providing all of our patients with exceptional care. When you have an appointment in our office, that time has been reserved exclusively for you! When a patient cancels without giving enough notice or fails to come for a reserved appointment it prevents another patient from being seen who is in need of dental care. Unforeseen events sometimes require a change of appointment. If you need to cancel or reschedule an appointment, we respectfully request notification of at least 48 hours in advance to avoid a charge. If you fail to arrive for your appointment and have not notified us 48 hours in advance, your account may be assessed a Missed Appointment Fee of $50.00 PER HOUR of reserved time. An appointment is considered missed/broken for one or more of the following reasons: 1. Failure to show up for a reserved appointment 2. Cancelling a reserved appointment without 48 hours notice 3. Showing up more than 15 minutes late for a reserved appointment I have read the Lybrook Dental Center Missed Appointment Policy and I understand and agree to this policy. Patient, Parent or Guardian Signature

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