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COOL SPRINGS PERIODONTICS & DENTAL IMPLANTS
HEATHER RIDGEWAY DDS,MS,PC
PATIENT INFORMATION & REGISTRATION FORM

Patient Information

Prefix

Mr. Mrs. Ms. Dr.

Patient Name

Patient Phone Numbers

Date of Birth / Email

Social Security Number / Employer

Home Address

Nearest relative not living with you

Phone

Whom may we thank for referring you?

Whom may we contact in case of an emergency

Emergency Contact / Relation

Phone / Relation

WHO WILL BE FINANCIALLY RESPONSIBLE FOR YOUR ACCOUNT

The following is for

self the patient's spouse the patient's parent or legal gaurdian Other

Name / Date of Birth

Social Security # / Employer

Phone Numbers

Address

SPOUSE OR OTHER GUARANTOR INFORMATION

The following is for

the pateint's spouse the person responsible for payment the patient's parent or legal guardian

Name / Date of Birth

Social Security # / Employer

Occurpation

Address

(Click here to add text)

Primary Dental Insurance

Name of Insured

Insured Date of Birth

ID# / Group #

Name of Insurance

Insured's Soc. Sec. #

Employer Name

Employer Address

City/State/Zip

Secondary Dental Insurance

Name of Insured

Insured Date of Birth

ID# / Group #

Name of Insurance

Insured's Soc. Sec. #

Employer Name

Employer Address

City/State/Zip

Patient's relationship to insured (PRIMARY)

self spouse child other

Patient's relationship to insured (SECONDARY)

self spouse child other

Name of Physician / Phone

Are you under the care of a physician now?

Yes No

Have you ever been hospitalized?

Yes No

Have you ever had major surgery or operation?

Yes No

Medications

Please list any prescription, nonprescription, or herbal medications you are taking, including aspirin

Medication Name

Allergies

Are you allergic to any medications?

Yes No

Do you have any disease or condition not listed above?

Yes No

Social History

Do you now or have you ever...

Smoked Cigarettes or used tobacco products?

Yes No

Amount per day / # of years

Drink alcoholic beverages

Yes No

Amount/week

Used recreational, illegal or IV drugs?

Yes No

Females Only

Are you pregnant, nursing, or plan to become pregnant?

Yes No

Do you take oral contraceptives?

Yes No

Signature

I certify that I have read & understand the questions above and that to the best of my knowledge, I have answered them accurately. I understand that providing false information could be dangerous to my health.

Click to Sign

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

Signature

These statements are true and complete to the best of my knowledge. I give my permission for my dentist and her clinical team to take any necessary diagnostic x‐rays, photos or study models to enable complete diagnosis and treatment. I also give my permission for any photos to be used for educational or scientific purposes.

Click to Sign

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

Financial Policy/Insurance Statement/Cancellation Policy

Thank you for choosing us to provide your periodontal care. We are committed to providing you with the highest quality periodontal services. Please read our financial policy. Our staff is available to answer any questions you may have.

A note about insurance
We are happy to assist our patients in preparing the forms necessary to obtain insurance benefits. Your insurance policy, however, is a contract between you, your employer and the insurance company. Payments for dental benefits are determined by a variety of factors, including the insured’s eligibility, limitations and exclusions (including pre-existing limitations), how much you and your employer paid for the plan, and conditions of the specific dental plan. The final determination of payment will be made at the time the claim is processed. Our relationship as your healthcare provider is with you. While we do our best to give you an accurate estimate of what your insurance will pay, each insurance policy is different and not all services we provide or may recommend are a covered benefit in all contracts. We base our treatment recommendations on your periodontal needs and not on what insurance will pay for. You are ultimately financially responsible for any balance remaining on your account after insurance has paid.

Financial Policy
1.   We ask that you pay for your initial examination and x-rays at the time of your visit. We accept cash, checks, Master Card, Visa and Discover. We will be happy to file your insurance claim for your reimbursement.

2.   For surgical visits, scaling & root planning & maintenance visits, we ask that you pay your estimated patient portion of the total charge, and/or any portion not covered by insurance on the day services are rendered. We will file the necessary paperwork for you that day to your insurance. Any credits or balances remaining will be settled after insurance has paid the claim. If you do not have insurance, we ask that you pay for the services in full the day services are rendered.

3.   You are responsible for any balance remaining on your account after insurance payment has been received.

4.   If your insurance company does not pay your claim within 30 days, it is your responsibility to contact your insurer to expedite payment.

5.   If your insurance company does not pay in full within 45 days, we require you to pay the balance in full by cash, check, Visa Master Card or Discover.

6. Accounts not paid past 60 days are subject to being turned over to a collection’s agency. In the event your account is turned over to an attorney/collection agency, you agree by signing below, to be responsible for the payment of a reasonable attorney/collection agency fee/cost incurred by the doctor in collection of your account.

Cancellations/No Shows
Patient care and timeliness are of utmost importance to us. We schedule and reserve time especially for you when we book an appointment. In order to accommodate our patients & to maintain the integrity of our schedule we ask for:

1.   2 business days (Mon-Fri) notice to cancel or reschedule a hygiene/maintenance/scaling &root planning appointment to avoid a $75 fee being charged to your account.

2.   3 business days (Mon-Fri) notice to cancel or reschedule a surgical appointment to avoid a $300 fee being charged to your account.

Patient or Financial Guarantor Signature

Click to Sign

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

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Demographic Information

Patient Information

Whom may we contact in case of an emergency

WHO WILL BE FINANCIALLY RESPONSIBLE FOR YOUR ACCOUNT

SPOUSE OR OTHER GUARANTOR INFORMATION

Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

MEDICAL HISTORY

Medications

Allergies

Have you had a reaction to

Health History

Do you have or have you ever had any of the following

Social History

Females Only

Signature

Click to Sign

Dental History

Dental Concerns - Have you ever experienced any of the following in your mouth?

Is there sensitivity in your teeth?

Please answer YES or NO

Signature

Click to Sign

Financial Policy/Insurance Statement/Cancellation Policy

Financial Policy/Insurance Statement/Cancellation Policy

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Main Header

Demographic Information

Patient Information

Whom may we contact in case of an emergency

WHO WILL BE FINANCIALLY RESPONSIBLE FOR YOUR ACCOUNT

SPOUSE OR OTHER GUARANTOR INFORMATION

Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

MEDICAL HISTORY

Medications

Allergies

Have you had a reaction to

Health History

Do you have or have you ever had any of the following

Social History

Females Only

Signature

Click to Sign

Dental History

Dental Concerns - Have you ever experienced any of the following in your mouth?

Is there sensitivity in your teeth?

Please answer YES or NO

Signature

Click to Sign

Financial Policy/Insurance Statement/Cancellation Policy

Financial Policy/Insurance Statement/Cancellation Policy

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

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