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In Case of Emergency

Please Contact:

Phone / Relation to Patient

Who will be responsible for your account

Who will be responsible for your account?

Self Spouse Father Mother Other

Responsible Party Name

Birth Date / Age / Soc. Sec. #

Phone / Driver's License

Address

City / State / Zip

Employer / Business

Spouse or other guarantor information (if different from above)

Name

Relation / Phone

Birth Date / S.S.#

Address

City / State / Zip

Employer / Business Phone

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

City / State / Zip

PRIMARY INSURANCE COMPANY

Employer / Business

Phone Number

Business Address

City / State / Zip

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?

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

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.)

Verification

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:-------------

FINANCIAL AGREEMENT
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available on the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service while minimizing our administrative costs.

All charges you incur are your responsibility from the date services are rendered, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is an agreement between you, your employer, and the insurance company. Our practice is not a party to that agreement. However, our office will continue to file your dental claims to your insurance company as a courtesy, with the benefits payable to you. This is a service we are happy to provide for our patients and we will work hard to ensure you are able to use your benefits to the fullest extent. In order for our practice to file your insurance claims, you must bring a copy of your insurance card and update the front office team with any changes.

All payments for treatment are due at the time of service. Our practice accepts cash, personal checks, Visa, Mastercard and Discover payments as well as third party financing through CareCredit and Proceed Finance. Complete Dentistry also extends a discount for payments made at the time of service. For cash and check payments we extend a discount of 5%, Visa/Mastercard Payments 4%, and Discover Payments 3%. For larger treatment plans and Invisalign we do customize inoffice payment plans depending on the length of treatment. If you have any questions about this information, do not hesitate to ask our front office team. WE ARE HERE TO HELP YOU.

I understand and agree that (regardless of my benefit company or plan) I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information noted above. If my account goes unpaid, I understand I will be responsible for a one-time charge of 35% collection fee as allowed in the State of Kentucky

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

Printed patient name

APPOINTMENT POLICY
We make every effort to value your time and we schedule your appointment time just for you.

We truly appreciate your courtesy of giving us a 48 hour notice if you have a conflict with your appointment and need to schedule a different day or time. We are committed to your oral health and keeping your scheduled appointment allows us to be partners in your dental care.

We will not charge you for a missed appointment. However, if you miss an appointment a second time you may be required to make a deposit when scheduling the next appointment. If you keep the appointment the deposit will be applied toward treatment. However, if you fail to keep the appointment a second time, the payment will be applied towards lost production time. For two or more missed appointments without a 48 hour notice, we will no longer be able to pre-appoint your dental visits and will offer same day scheduling for 1 year. Meaning, you will need to call and request an appointment on the day you are available and if we have an appointment available, we will see you on that day.

It is our philosophy that this policy allows us to put our patients first and make your experience a positive one. Thank you for allowing us to share our missed appointment policy with you and please let the front office know if you have any questions.

Appointment Agreement:
• I acknowledge an appointment is a reservation.
• I agree to provide a minimum of 48 hour notice if I need to change my appointment for any reason.
• If I change 2 appointments without the required 48 hour notice in a 12 month span, I acknowledge I will not be able to reserve pre-appointed time for 12 months.

Signature of patient: (Parent or Guardian if Minor)

Click to Sign

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

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.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

truForm by PBHS

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

General Insurance Information

School Information

PRIMARY INSURANCE COMPANY

Dental Information

Dental Information

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

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:

Conclusion

This section is for women only

Verification

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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

General Insurance Information

School Information

PRIMARY INSURANCE COMPANY

Dental Information

Dental Information

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

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:

Conclusion

This section is for women only

Verification

Click to Sign

Click to Sign

Click to Sign

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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Please open a new browser window and reload the form.