1. What is the main reason for today's visit?
2. Have you ever had any complications following dental treatment?   Yes  No 
   If Yes, please explain:
3. Name (optional) of previous dentist & date of last dental visit
4. Do you like your smile?   Yes  No   If no, what would you like to change:
5. Name & Phone Number of Physician:
6. In case of emergency, contact: (name & phone numbers)
7. Have you been admitted to a hospital or needed emergency care during the past two years?   Yes  No 
   If Yes, please explain:
8. Do you have any health problems that need further clarification?  Yes  No 
   If Yes, please explain:
9. Are you taking any blood thinning medications(s)? Yes  No 
10. List all medications you are currently taking:
11. Have you ever taken prescription medications for weight loss (Diet pills)   Yes  No  
    If yes, did you take any of the following?
    Fen-Phen (Fenfluramine-Phentermine)
    Pondimen (Fenfluramine)
    Redux (Dexfenfluramine)
    If yes to any of the above, did you have a medical exam for heart issues? Yes  No
12. Whom may we thank for referring you to our office? 

     The Department of Health Services has established a "Privacy Rule" to help insure that personal healthcare information is protected for privacy.  The Privacy Rule was also created for uses and disclosures of health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or healthcare operations.

     As our patient we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy.  We strive to always take reasonable precautions to protect your privacy.  When appropriate we provide the minimum necessary information to only those we feel are in need of your health care information.  This includes information about treatment, payment, and/or health care operations in order to provide health care that is in your best interest.

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of 's (name of patient) dental needs.
    
2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agree upon by me and to employ such assistance as required to provide proper care.
3. I agree to the use of anesthetics, sedatives and other medication as necessary.  I fully understand that using anesthetic agents embodies certain risks.  I understand that I can ask for a complete recital of any possible complications.
4. I understand that I will be given the opportunity to discuss my treatment with the doctor and financial arrangements will be agreed upon before treatment is begun.
5. If care is being rendered on a minor child, I authorize the doctor to obtain the x-rays and to treat the minor child as needed.  I understand I will be given the opportunity to discuss the treatment plan with the doctor and that I as the parent/guardian, which accompanies the child to the office is responsible for payment.
6. I agree to be responsible for payment of all services rendered on my behalf or my dependents.  I understand that payment is due at the time of service unless other arrangements have been made.  In the event payments are not received by agreed upong dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account.  As required, I also understand a check of my credit history may be made.

Patients Signature________________________ Date_________ Witness__________________________

Parent/Guardian's Signature____________________ Relationship to Patient________________________

Office Guidelines

Financial Responsibility

1. Balances remaining beyond 30 days from billing will accrue interest at a rate of 1.5% per month (18% Annual Rate).
2. There is a $25.00 charge for all returned checks.
3. Personal credit may be checked.
4. In the event of default, I promise to pay legal interest on the indebtedness, collection costs, and related attorney's fees.

Dental Insurance

We are happy to file forms necessary to see that you receive the full benefits of your coverage.  However, we cannot guarantee any estimated coverage.  Unless prior arrangements are mad you will be expected to pay your portion as services are provided.  Please keep in mind that we can only estimate your portion.  If there is a difference after your insurance company has paid, it is your responsibility to pay the difference.  Because with your insurance policy is a contract between you and the insurance company, we will not enter a dispute with your insurance company over a claim.  We will provide information to support the necessity for treatment, which may assist you in recovering your benefits.  Any balances not paid by the insurance company within 60 days of submission becomes your responsibility to pay at this time.  My signature will authorize assignment of insurance benefits to this office.

Payment Options

Cash or check: We are able to offer a 5% pre-payment courtesy for treatment that exceeds $1,000 and paid in full at the time of treatment.

Credit Card: We accept payment by several major credit cards as well as bank debit cards.

Payment Plan: For our patients who desire a monthly payment plan, we have several options which can be processed quickly.  Our financial coordinator will be happ to help you with these.

Optional Payment Plan:  If multiple appointments are required, you may divide half of your payment at the start of treatment and the balance upon completion.

My signature will authorize assignment of insurance benefits to this office.

Patient's Signature:_________________________________    Date:_________________