Patient Information Patient’s Name



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Patient Information
Patient’s Name: ________________________________________________ Birth date: ____________________

Male Female Married Single Child Other

Please let us know how you heard about our office: _______________________________________________



-Contact Information-

Address:

Street Apartment #

___________________________________________________

City State Zip Code


Phone (Home): ________________ (Work): ________________ Ext: ______ (Cellular):
Email address: ________________________________May we send email appointment reminders? __________
Social Security Number_____________________________ Driver’s License Number______________________
Employer Name: _________________________________________ Occupation: _________________________

Address:

Street Phone #

____________________________________________

City State Zip Code

Spouse’s Name_________________________________________ Birth date______________

Employer Name: _________________________________________ Occupation: _________________________

Address:

Street Phone #

____________________________________________

-Insurance Information-
*Primary Insurance Company Name and Address_____________________________________________________

Subscriber Name________________________________________________________________

Subscriber Social Security Number________________________ Birth date __________Group Number_________
*Secondary Insurance Company Name and Address ________________________________________________

Subscriber Name________________________________________________________________

Subscriber Social Security Number________________________ Birth date __________Group Number_________

Emergency contact: (someone other than responsible party) _______________________________________

Address:_________________________________________________________Phone _____________________


Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement 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.
A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
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.
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.
____________________________________________________ Date: _____________ Relationship to Patient:

Signature of patient, parent or guardian


____________________________________________________ Date: _____________ Relationship to Patient:

Signature of guarantor of payment/responsible party


Medical History

Check () if you have or have had any of the following:


    • Anemia

    • Arthritis

    • Asthma

    • Back/Neck Pain

    • Bulimia/Anorexia

    • Cancer

    • Diabetes

    • Dizziness

    • Emphysema

    • Epilepsy

    • Excessive bleeding

    • Fainting

    • Fibromyalgia

    • GERD/ Gastric reflux

    • Glaucoma

    • Hay Fever



    • Artificial joints

    • Blood disease

    • Chemical dependency

    • Chemotherapy

    • Circulatory problems

    • Headaches

    • HIV/ AIDS

    • Jaw pain

    • Radiation Treatment

    • Thyroid problems

    • Tobacco habit

    • Tonsillitis

    • Hemophilia

    • Taking Fosamax or other bisphosphonates

    Heart Disease-

    • Chest pain

    • Irregular heartbeat

    • Artificial heart Valves

    • History of infective

    Endocarditis

    • Head Injuries

    • Hepatitis

    • High blood pressure

    • Kidney Disease

    • Liver Disease

    • Lumps/swelling

    • Osteoporosis

    • Psychiatric care

    • Respiratory problems

    • Rheumatic fever

    • Shortness of breath

    • Sinus problems

    • Sleep Apnea

    • Stomach Problems

    • Stroke

    • Tuberculosis



Physicians Name: Date of Last Visit:

Have you had any serious illnesses or operations? If yes, Describe:

____________________________________________________________________________________________

Have you ever been told you need to take an antibiotic or pre-med prior to your dental appointment? Yes No

If yes, please explain:


(Women) Are you Pregnant? Yes No Nursing? Yes No Taking Birth control Pills? Yes No

Allergies Medications



List Medications you are currently taking:_______________________________________________________________________________________________________________________________________________________________________________________________

List Supplements you are taking: _______________________________________________________________________________________________________________________________________________



  • Aspirin

  • Barbiturates

  • Codeine

  • Local anesthetic

  • Penicillin

  • Sulfa

  • Latex

  • Other___________





Dental History


Reason for today’s visit: ___________________________________ Date of last dental exam/X rays:___________________

Former Dentist: __________________________________________ Phone# _____________________________________



Check () if you have or have had any of the following:


    • Bad Breath

    • Bad dental experience

    • Burning sensation on tongue

    • Broken fillings

    • Pierced Tongue

    • Reactions to anesthetics

    • Sensitivity to cold

    • Sensitivity to heat

    • Chew on only one side of mouth

    • Clicking, popping or locking of jaw

    • Difficult extractions

    • Dry mouth

    • Mouth breathing

    • Orthodontic treatment

    • Pain around ear

    • Sensitivity to sweets

    • Food collection between teeth

    • Grinding/ clenching

    • Gums swollen/tender

    • Headaches

    • Jaw pain or tiredness

    • Loose teeth

    • Periodontal therapy/or Deep Cleaning





    • Gum Chewing Tobacco Use

    • Mint/ hard candy use Cigarettes PipeChewPatchOther


How often do you Brush?_____________________________ How often Do you Floss?_____________________________


 Are you happy with your smile? YesNo What would you like to see changed?________________________________

Signature

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Signature of patient, Parent, Or Legal Guardian:______________________________________________ Date:_______________________________

Please print name of above: __________________________________________________________ Relationship to patient:_____________________

HIPPA

All Smiles Dentistry

9623 32nd ST NE, B105

Lake Stevens, Washington 98258

425-335-1111

Acknowledgement of Receipt of Statement of Privacy

I acknowledge that I have received a copy of the statement of privacy practices for the office of All Smiles Dentistry. The statement of privacy practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of health care operations. The statement of privacy practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The statement of privacy practices is also posted in the facility.


All Smiles Dentistry reserves the right to change the privacy practices that are described in the statement of privacy practices. If privacy practices changes, I will be offered a copy of the revised statement of privacy practices at the time of my first visit after the revisions become effective. I may also obtain a revised statement of privavcy practices by requesting that one be mailed to me.


Additional Disclosure Authority



In addition to the allowable disclosures described in the statement of privacy practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.


ANY MEMBER OF MY IMMEDIATE FAMILY Yes No



SPOUSE ONLY Yes No



OTHER (please Specify): Yes No

DATE ________/_______/_________ Relationship to patient ______________________________




OFFICE USE ONLY BELOW THIS LINE


Record of Acknowledgement not obtained

Provided prior to treatment? Yes No Date Provided: _________/______/__________

Reason for Denial:
Needed more time to review statement of privacy practices. Unable to sign. Other:_____________

Wanted to consult with another person before signing. Reason not given.



FINANCIAL & APPOINTMENT POLICY

We are committed to providing you with the best possible care and to a trusting partnership with you in your dental care. Your clear understanding of our Financial and Appointment Policy is important to our professional relationship. Please ask if you have any question about our fees, Financial and Appointment Policy, or your responsibility at any time.



Your Payment is due at the time of treatment
Payment for treatment is due at the time services are rendered. Prepayment for all laboratory fabricated dental treatment is required (crowns, onlays, bridges, dentures, etc.). We accept most major credit cards, personal check, money orders or cash. If you prefer a deferred payment option we offer Care Credit, simply ask for a short application and/or apply online.
Dental Benefits (Insurance) – We go the extra mile
If you have dental benefits, we will make a good faith estimate of your benefits and defer billing you for that amount for up to 60 days. As a courtesy to you, we will file the appropriate claim forms with your dental benefit company. We will also track your dental claims, follow-up with your benefit provider when claims are not processed in a timely manner and attempt to expedite payment. We are also happy to provide your benefit carrier with x-rays or other information they may require in accordance with the Health Insurance Portability & Accountability Act (HIPAA).
If your dental benefit carrier denies coverage, or if we otherwise do not receive payment within 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your benefits carrier and/or your employer and your benefits provider. We will make every attempt to assist you in obtaining any benefits due you by your dental benefit provider.
For all Patients: Please help us to serve you, and our other patients, by keeping your scheduled appointments. We do require at least 48 HOURS NOTICE for any scheduling changes to avoid an appointment charge. To help compensate the cost of lost appointments, there will be a broken appointment charge of $50.00 per each half hour of scheduled time.

I understand that any delinquent balances are subject to a Finance Charge of 1% every month until balance is paid in full. Regardless of dental benefit coverage, I am responsible for the entire fee for any treatment rendered and any related expenses. I understand that I am responsible to pay reasonable attorney’s fees and collection expenses incurred and expended in the event should my account be referred to an attorney or agency for collection.


Assignment and release: I authorize payment to be made directly to the dentist by my dental benefit company. I accept financial responsibility for all services whether covered or not by my dental benefit provider and I authorize release of any dental or medical care information requested by my benefit carrier.
Thank you for understanding our Financial & Appointment Policy. Please let us know if you have any questions.

_________________________________________________________

Patient Signature Date

_________________________________________________________



Responsible Party Signature if different than Patient




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