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In Case of Emergency

Please Contact

Phone/Relation

Who will be responsible for your account

Who will be responsible for your account?

Self Spouse Father Mother Other

Responsible Party Name / SSN

Date of Birth / Age

Phone / Drivers license

Address

City / State / Zip

Employer / Business

Spouse or other guarantor information (if different from above)

Spouse or other guarantor Name

Birth Date / Social Security Number

Address

City / State / Zip

Employer / Business

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

City/State/Zip

Primary Insurance Information

Insurance Type:

Dental Medical

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co Name

Policy I.D. Number

Insurance Co Address

City / State / Zip

Phone Number

Group

Insured Party

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / SSN#

Secondary Insurance Information

Insurance Type:

Dental Medical

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co Name

Policy I.D. Number

Insurance Co Address

City / State / Zip

Phone Number

Group

Insured Party

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / SSN#

Dental Information

Reason for today’s visit

Are you in pain?

Yes No

For how long?

Dental Information Part 2

Please indicate any of the following problems by clicking "yes" on the corresponding question

Are you taking any kind of medication, drug, pills?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Please list any other medication or antibiotic you are allergic to:

This section is for women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

(Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.)

Certification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

I permit the office to communicate with me via text message on my cell phone.

Yes No

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

Reviewed by

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Date:-------------

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies fix allowances for certain procedures while others pay a percentage of the charge. It is your responsibility to pay any deductibles, coinsurance or any other balances not paid by your insurance company. Any accounts with an unreimbursed balance over 120 days will incur a .25% finance charge. If we have to refer your account out to a third party for collection, you will be responsible for all collection fees, court costs attorney fees. We include a 3% surcharge for all credit card transactions. However, debit, cash and check payments do not incur this fee.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

CONSENT FOR USE & DISCLOSURE OF HEALTH INFORMATION

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting the office staff at this office location.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal representative's name (Please Print)

Click to Sign

Date:-------------

INFORMED CONSENT FOR ROOT CANAL THERAPY

Endodontic (root canal) treatment is a procedure through which infected teeth may be saved. Root canal treatment works by removing bacteria and irritants from the hollow space inside the tooth, and by sealing off the inside of the tooth to prevent re-infection. Although root canal therapy has a very high success rate, it is a biological procedure and cannot be guaranteed. Occasionally, a tooth which has had root canal treatment may require retreatment, additional surgery, or extraction.

I understand the alternatives to root canal treatment are extraction of the involved tooth or postponement of root canal therapy. I realize that postponement of treatment may result in future loss of the tooth. I understand the possible risks of root canal therapy, although rare, do exist, and include (but are not limited to) pain, infection, swelling, fever, changes in occlusion (bite), reaction to medications or anesthetics, nerve injury following local anesthesia, temporal mandibular (jaw) joint pain, difficulty opening and closing. I understand the possible complications of root canal therapy, although rare, do exist, and include (but are not limited to) instrument breakage in the root canal, inability to negotiate canals due to prior treatment or calcification, perforation to the outside of the tooth, irreparable damage to the existing crown or restoration, and cracking or fracturing of the root or crown. I understand that medications administered or prescribed for me may have risks and adverse reactions which may impact my general health. Some medications may cause nausea, vomiting, allergic reactions, drowsiness, and impairment of motor and cognitive skills. Use of other drugs or alcohol along with some prescribed medications may result in detrimental side effects or interactions. Do not operate any vehicle or hazardous device when under the effects of some prescribed medications. Antibiotics may affect the effectiveness of birth control pills; alternative precautions should be utilized. I understand that permanent restoration of my endodontically treated tooth is necessary within 6 weeks of the completion of my endodontic treatment. I realize that this is my responsibility, and failure to have the permanent restoration placed by a dentist may lead to failure of the root canal treatment. I understand that it is not within the domain of my endodontist to perform this service.

All my questions have been answered, and I have carefully read and understand the above information. I give my consent for the procedure.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

DENTAL INSURANCE

If you are covered by dental insurance, it is important for you to be informed that our professional services are rendered to you and charged to you, NOT the insurance company.

It is the policy of this office to estimate your out of pocket expenses with the understanding if your insurance does not pay what we estimate the balance will be due from you.

I have read and fully understand the above office policy regarding Insurance. If my insurance plan is not listed below, I realize I am utilizing an OUT OF NETWORK provider and by doing so my reimbursement will be less from my insurance company. I also understand the only plans the office participates with are:

• Delta Dental Plan (Premier/PPO)(Clear)
• Horizon Blue Cross Blue Shield (Trad/Dental Option only)
• Assurant (DHA)
• DeCare Dental (Teamsters)
• Careington/Guardian PPO

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

I agree to be responsible for dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charge. To the extent permitted under applicable law, I authorize release of any information relating to this claim.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

I hereby authorize payment of the dental benefits otherwise payable to me to the treating dentist.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

HIPAA

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

I give permission to discuss any pertinent health and / or billing questions with:

Name

Relationship/Phone#

Name

Relationship/Phone#

Name

Relationship/Phone#

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

Main Header

Demographic Information

Patient Information

In Case of Emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

School Information

General Insurance Information

Primary Insurance Information

Secondary Insurance Information

Dental Information

Dental Information

Dental Information Part 2

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

Medications / Allergies

Are you now taking:

Please list any medications you are currently taking

Are you allergic or had a reaction to:

Please list any other medication or antibiotic you are allergic to:

This section is for women only

Conclusion

Certification

Click to Sign

Click to Sign

FEES & PAYMENTS

Click to Sign

Click to Sign

CONSENT FOR USE & DISCLOSURE OF HEALTH INFORMATION

Click to Sign

Click to Sign

INFORMED CONSENT FOR ROOT CANAL THERAPY

Click to Sign

DENTAL INSURANCE

Click to Sign

Click to Sign

Click to Sign

HIPAA

Click to Sign

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