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Dentistry design for your perfect smile. We’re pleased to have you as a client and want to assure you that we intend to do everything possible to ensure your comfort and confidence in our services. We strive to provide the highest quality care using only the very best, proven techniques and materials — while catering to your ultimate relaxation in a pampering, nurturing environment. Please take a few minutes to complete the following profile. This information is required and will be considered strictly confidential.
whom may we thank and reward for referring you? are you delighted with your smile 2 yes 2 no (if no, why?) rate your smile from 1-10 (10=awesome) if you could wave a magic wand, what would you change about your smile? would you like to have whiter teeth 2 yes 2 no what personal/professional benefit might you gain with a perfect smile do you need dental work completed in time for an upcoming special occasion (please explain) Please check the procedures below that you feel would improve your smile: date of last dental exam were x-rays taken was treatment recommended was treatment completed do you breathe thru your mouth while awake or asleep do you experience pain when cleaning teeth have you ever been under the care of a periodontist are your teeth sensitive to temperature or pressure have you ever had pain in either jaw joint do you have chronic headaches, neck or shoulder pain do you require antibiotics before dental treatment are you aware of any sores or growths in your mouth are you aware of clicking or popping in either jaw joint If so, when: 2 while awake 2 while asleep have you ever had complications after dental treatment 2 yes 2 nowould you like to speak to the doctor privately do you have a personal physician 2 yes 2 no are you currently under the care of a physician 2 yes 2 no your current health is: 2 excellent 2 good 2 fair 2 poor date of last physician visit: do you smoke or use tobacco in any form: 2 yes 2 no are you taking any prescription/over the counter drugs (list all) are you taking birth control pills: 2 yes 2 no are you pregnant: 2 yes 2 no week # are you nursing: 2 yes 2 no have you had any recent: surgeries? 2 yes 2 no have you ever had a blood transfusion? 2 yes 2 no have you ever had any of the following diseases or medical conditions: are you allergic to any of the following: To the best of my knowledge, all of the preceding answers and information provided are true and correct.
signature of patient, parent, or guardian As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimburse- ment from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
As a courtesy, our office will call to remind you of your appointment 48 hours in advance. Please be considerate to our doctors, hygienists, and our other patients waiting for an appointment by giving us 48 hour advance notice of any change in your scheduled appointment. We understand that emergencies may arise that will result in cancellation. Please understand that we cannot guarantee that you will be appointed to the same time slot. We may require advance payment of your appointment if cancellations occur greater than two (2) times (or become habitual).
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. In order to continue to assist our patients with dental insurance, we require that patients have a credit card on file in our office. Once insurance has paid their portion, your credit card will be charged the balance. If we have not received payment from your insurance company within 60 days after filing your claim, your credit card will be charged for the outstanding balance. For your convenience, we accept the credit cards listed below, as well as personal checks, third-party financing with CareCredit, and cash. As always, we extend a courtesy discount to our patients who pay in full at the time of service and have their insurance company reimburse them. This courtesy applies to restorative treatment only. We are happy to file all necessary paperwork to your insurance company to support your claim. Out team is also here to assist you with all third-party applications if you are interested in applying for financing. Please be assured that our office protects your personal and financial information as regulated by the Health Insurance Portability and Accountability Act of 1996 or HIPPA. Patients who choose not to leave a valid credit card on file with our office understand they must pay for their dental care in full on the day of service, and insurance will be filed to reimburse them for their services according to their schedule of benefits. Your signature below authorizes our office to charge your credit card.
Credit Card: 2 Visa 2 MasterCard 2 Discover 2 American Express I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content.
signature of patient, parent, guardian, or guarantor of payment date signature of guarantor of payment/responsible party

Source: http://www.alpharettadentist.co/wp-content/uploads/2010/10/Health-History.pdf

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