Murrayhilldentistry.net

Welcome to Manhattan Dental Studio, where delivering quality dental care for optimal health is
our main objective. You can rest assured in knowing that Dr. Tomack and Dr. Behrens have your best interest in mind. Patient Name___________________________________________________________________ SS# _____________________________________ Date of Birth _________________________ Address_______________________________________________________________________ City State Zip _____________________________ Email ______________________________ Telephone Home/Cel /Work______________________________________________________ Emergency Contact & Phone ______________________________________________________
INSURANCE
(If you have secondary insurance info please inform the front desk staff.) Name of Policy Holder (If different than above) _______________________________________ Policy Holder Date of Birth _______________ Policy Holder SS# _______________________ Employer _____________________________________________________________________ Name of Insurance __________________________ Ins Phone # _________________________ Insurance Address_______________________________________________________________ Member ID #_____________________________ Group #______________________________ Whom may we thank for your referral? _______________________________________________ In consideration of the others who need care, if you are unable to keep an appointment we ask that you please give at least a 24 hours notice. There is a $25.00 broken appointment fee that applies
should you cancel or reschedule within 24 hours of your appointment time, which we donate to St. Jude Hospital on your behalf.
AUTHORIZATION & CONSENT
I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits or to I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to
me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less
than the actual bill for services. I understand I am financial y responsible for payments in full of al
accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be
responsible for payments of services not paid, by my dental care payor. I attest to the accuracy of the Signature______________________________________________________ Date__________ NOTICE OF PRIVACY PRACTICES (Please see attached Take Home Hand Out)
This notice says that we wil not share your information with a third party without your consent. I acknowledge that I have received and read a Notice of Privacy Practices in its entirety from Manhattan Dental Studio. Signature____________________________________________Date_____________
DENTAL HISTORY
Reason for today’s visit ___________________________________________________________ Date of last dental visit ____________ Former Dentist__________________________________ Date of last dental x-rays ____________ Do You Use: Floss? Yes No Electric Tooth Brush? Yes No Are you happy with the appearance of your teeth and your smile? Yes No If Not, what would you like to change?__________________________________________________________________ Are you interested in having whiter teeth? Yes No Have you ever had an allergic reaction to Novocain, local, or general anesthetics? Yes No If Yes, please explain _____________________________________________________________ Have you ever had trouble from previous dental care? Yes No If Yes, please explain ______________________________________________________________________________ (If additional space is needed, please list on the bottom of this form) Any comments or anything else we should know about your dental health? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signature______________________________________________________ Date__________ MEDICAL HISTORY
Are you currently under the care of a Physician? Yes No If so, for what? ______________________________________________________________________________ Physician’s name ___________________________________ Date of last visit________________ Are you taking any medication?_____________________________________________________ (If additional space is needed please list on the bottom of this form) Are you al ergic to any medication, i.e. local anesthetic, Penicillin, Aspirin, Sulfa, Codeine? –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Do you smoke? Yes No How much?________________________________ Do you consume alcoholic beverages? Yes No If so, how many per week?__________________ Have you had any serious il nesses, operations or blood transfusions? Yes No If yes, please describe _______________________________________________________________________ (Women) Are you pregnant? Yes No Due date _________________ Nursing? Yes No If you answered yes, to any of the questions above please explain. Is there anything else about your health that we should know? ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Signature _______________________________________________ Date _____________ INSURANCE AND FINANCING
We understand that insurance can be confusing. Please know that we are here to help in any way we can, but we do not control what the insurace company wil cover or reimburse you. The insurance is an agreement between you, your employer and the insurance company. We do not dictate how or what the insurance company wil pay. We encourage you to become familiar with your policy exclusions and deductibles. We wil always help our patients maximize their benefits, including same day electronic form filing with the insurance company. Patients are ultimately responsible for
the full cost of treatment, whether or not we accept assignment of benefits.
Our expectations of you as the owner of the policy: 1. Payment of fees not covered by your insurance plan at the time the service is rendered 2. Researching your dental insurance plan to advise you of benefits available to you 3. Understanding that the insurance policy belongs to you and we have no leverage to obtain 4. Realize that dental insurance policies restrict payment for some services, use restricted fee schedules (cal ed usual and customary rates) and exclude some procedures based on prior conditions or length of time on the plan. Al restrictions are based on the premium paid for insurance, not our fees or recommended treatment 5. Keeping our office informed of any changes in your insurance coverage 6. Taking responsibility for payment if the insurance company does not pay our office within 45 days - or for any unpaid balance - with a pre-arranged credit card authorization I hereby authorize benefits to be paid directly to Dr. Tomack and Dr. Behrens of Manhattan Dental Studio. I understand that I am responsible for any unpaid balance. Card Number________________________________________ Exp. Date___________ I give permission to settle my balance with the above credit card information for any outstanding balance after 45 days. Print Name__________________________________________ Date_____________ Signature____________________________________________Date_____________
VELSCOPE- ORAL CANCER SCREENING

We know that oral cancer claims one life every hour in the US – more than the number of lives lost
to skin cancer, cervical cancer or Hodgkin’s disease, and it is of great concern to our doctors and Oral Cancer is one of the most curable diseases when caught early. This practice has incorporated the Velscope Oral Cancer Screening technology into the standard of care of the practice. Velscope technology uses a wavelength of light which causes normal tissue to fluorescent green. Diseased tissue lacks this fluorescence. This allows us to see the diseased area before it is visible to the naked eye. It is a simple, painless and non‐invasive technology that improves the Doctor’s ability to visualize, mark, evaluate and monitor suspicious areas at their earliest stages, before they can progress to something far more serious, and potential y life‐threatening. Risk factors and Screening Recommendations: • The incidence of oral cancer in young adults is increasing • 50% of al newly diagnosed oral cancers are in individuals who do not have the historic risk factors • It is believed that the increase in oral cancers is due to HPV (human papil oma virus) as the majority of these tumors have the virus present in the tissue. • The good news is that these cancers can be discovered and treated early with good results. • The Oral Cancer Foundation now recommends an annual screening for anyone old enough to engage in sexual behaviors in order to catch the disease at its earliest possible stages. The cost for this screening is $28.00; and we recommend that this be done once per year. We will be happy to submit to your insurance company on your behalf. I _________________________________ WOULD like this screening. I _________________________________ DO NOT want this screening at this time. _____________________________ __________________

Source: http://murrayhilldentistry.net/_clientfiles/documents/New.Patient.Paperwork.pdf