Home Phone#:_______________________Cell#:_______________________ Work #:________________________
DOB:__________________ Social Security#:_______________________ E-mail:____________________________
Employer:______________________ Work Address:___________________________________________________
Street City State Zip
Person Responsible for Payment (If other than the patient. If minor, please list the parent’s/guardian’s name(s).) Name:_________________________________________________ Driver’s Lic# & State:______________________
If you have dental insurance, please fill out the following information. As a courtesy to our patients, we will file most primary dental insurance coverage. However, if a patient carries a secondary dental coverage it will be the sole responsibility of the patient to file for those benefits due to length of time involved in payment of claims process. (We are OUT OF NETWORK ON PLANS OTHER THAN DELTA DENTAL AND ASSURANT)
Primary Dental Insurance (need a copy of the insurance card AND driver’s license)
Name of Insured (the employee):__________________________________________________________________
Insurance Phone#:_________________ Group #:____________________ Policy ID# :________________________
Insured’s Social Security # :_________________________ Insured’s DOB:________________________________
Minor: I, being the parent/guardian of the above named minor patient, do hereby authorize the performance of dental services upon this patient and whatever procedures the judgment of the doctor may dictate in order to carry out treatment procedures as outlined in the treatment plan form. I also authorize and request the administration of such anesthetics, sedatives and/or x-rays as may be deemed advisable by the doctor. Adult: I hereby consent to the treatment indicated on the examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.
I understand that my dental care insurance carrier or payer of my dental benefits may allow less than the actual bill of services. I understand I am financially responsible for payment in full of all accounts. By signing this statement, I agree to be responsible for payment of services not paid, in whole or in part, by my dental care payer. Furthermore, I agree to pay for all services rendered by this office.
I attest to the accuracy of the information on this page. And to the best of my knowledge all questions have been answered accurately. I understand that providing incorrect information can be dangerous to my (or the patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. HIPPA Compliance: I have had full opportunity to read and consider the contents of the Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations. _____________________________________________________________________________________________________________________
Signature of Responsible Party Relationship to patient Date Whom may we thank for referring you? __________________________ or How did you hear about us?__________________
DENTAL & MEDICAL HISTORY Does dental treatment make you nervous? Slightly Moderately Extremely
What do you fear most about dental care? ________________________________Date of your last dental visit?_____________
Have you ever been treated for periodontal disease (gum disease)? Yes No
Do you have mouth/soft tissue problems:
Bleeding, sore gums Yes No Frequent blister on lips, mouth Yes No
Unpleasant taste, bad breath Yes No Swelling, lumps in mouth Yes No
Do you have any specific problems with your teeth: Sensitive to sweets Yes No Sensitive to biting Yes No
Uncomfortable bite Yes No Sensitive to hot Yes No Food Impaction Yes No
Loose teeth Yes No Sensitive to cold Yes No
Do you have any jaw joint problems:
Clicking or popping when opening or closing Yes No Pain in the jaw joint Yes No
Difficulty opening or closing jaw Yes No Headaches Yes No
Clenching or grinding Yes No Ringing in the ears Yes No
These are the things that are important to me about my dental health:______________________________________________
Circle one for questions A & B: A: 1.My mouth is very comfortable. B. 1. I think the appearance of my smile is excellent. 2. My mouth is uncomfortable. 2. I am dissatisfied with the appearance of my smile.
Would you like to have whiter teeth? Yes No Would you be interested in a smile makeover? Yes No
Would you prefer to be sedated should you need dental work? Yes No
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Physician’s Name:_______________________________________Phone:____________________________
Have you ever been hospitalized or had a major operation?Yes No Describe:________________________________
Have you ever had a serious head or neck injury? Yes No Describe:________________________________
Are you taking any prescription medications? Yes No Please List All Medications:_____________________
Do you take or have your taken Phen-Fen or Redox? Yes No Are you on a special diet? Yes No
Do you use controlled substances? Yes No Do you use tobacco? Yes No
Woman: Are you pregnant or trying to get pregnant? Yes No Nursing? Taking any oral contraceptives?
Have you ever had an allergic reaction to bananas? Yes No
Are you allergic to: Aspirin Penicillin Metal Local Anesthetics Acrylic Codeine Latex Other___________________
Do you have or have you had any of the following: Aids/HIV Positive
Patient’s Name DOB Today’s Date
PLEASE INITIAL EACH PARAGRAPH AFTER READING. IF YOU HAVE ANY QUESTIONS, PLEASE ASK YOUR DOCTOR BEFORE INITIALING. _____ 1. TREATMENT:
I understand that I may have the following dental treatment performed: Fillings, Crowns, Bridges, Dentures, Extractions, Impacted Tooth Removal, Root Canals, Implants, treatment of periodontal disease or other work deemed necessary.
_____ 2. DRUGS AND MEDICATIONS:
I understand that antibiotics, analgesics, anesthetics and other medications can cause allergic reactions, resulting in redness and swelling of tissues, itching, pain, nausea, and vomiting or more severe allergic reactions. I have informed the doctor of any known allergies. Certain medications may cause drowsiness and it is advisable not to drive or operate hazardous equipment when using such drugs.
_____ 3. RISKS OF DENTAL ANESTHESIA:
I understand that pain, bruising, and occasional temporary or sometimes-permanent numbness in lips, cheeks, tongue or associated facial structure can occur with “shots”. About 90% of these cases resolve themselves in less than 8 weeks. Although very rarely needed, a referral to a specialist for evaluation and possibly treatment may be needed if the symptoms do not resolve.
_____ 4. FILLINGS:
I understand that a more extensive restoration than originally planned, or possibly root canal therapy, may be required due to additional conditions discovered during preparation. I understand that significant changes in response to temperature may occur after tooth restoration. I realize that fillings are rarely “permanent” and usually require periodic replacement with additional fillings and/or crowns.
_____ 5. CROWNS, BRIDGES, INLAYS AND ONLAYS:
I understand that it is sometimes not possible to exactly match the color of natural teeth with artificial teeth. I further understand that I may be wearing temporary crowns that are prone to loosening and may need re-cementing. I will notify my doctor of that occurrence so that a temporary restoration is maintained until the final restoration is delivered. I realize that any changes I may desire in color, shape, size, etc. of a crown must be made prior to final fabrication. It is my responsibility to return within one month of tooth preparation for final cementation of the restoration. I understand I may need further treatment in this office or possibly by a specialist if complications arise during treatment, and any costs thus incurred are my responsibility.
_____ 6. DENTURES:
I understand that wearing dentures is not a simple process, that chewing efficiency will be diminished, and that dentures are not “permanent”. I also understand that, while I will no longer suffer from dental decay or infection, I could experience denture related problems such as: shrinking bone and gums, poor chewing ability, altered speech, reduced taste and constant denture movement. Most denture wearers become used to these symptoms quickly while others take time and there is a small number of patients who never do. Immediate dentures (placement of a denture immediately after extractions) may be quite uncomfortable for several days. Immediate dentures require frequent adjustments and one or more permanent relines within several months. I understand that failure to keep appointments may result in a less than desirable outcome. If a remake is required due to my delay, additional fees may be incurred.
_____ 7. EXTRACTIONS:
Alternatives to tooth removal include root canal therapy, extensive restoration, periodontal (gum) treatment or crowns. I understand that removing teeth does not always remove existing infection and that further treatment may be necessary. I understand that the risks of removing teeth include, but are not limited to: pain, swelling, bleeding, infection, dry socket, fracture of bone or jaw, and loss of feeling in my lip or other facial areas, cheek, tongue, gums and teeth. Such numbness may be temporary or permanent. Also, there is the possibility of a small root piece being left in the jaw where the risks of removing it outweigh the benefits. I understand that further care by a specialist may be needed if complications arise during or after treatment, and that costs incurred are my responsibility.
_____ 8. PERIODONTAL TREATMENT:
Periodontal disease can be a serious condition, causing gum and bone inflammation and/or loss and may lead to loss of permanent teeth. Possible treatment plans have been explained to me, including deep cleaning, gum surgery and bone grafting, extraction of teeth and tooth replacement. I understand that much of the success of periodontal treatment depends on my continuing home care and faithful adherence to following my doctor’s instructions, including strict observance of recall appointments. I understand that care by a specialist may be necessary.
_____ 9. ROOT CANAL THERAPY:
I realize root canal therapy has a very high success rate; however, there is no guarantee that root canal treatment will save a tooth, and complications may occur. During the procedure some complications or conditions might be noticed which would require a referral to a specialist or extraction. These include: extensive decay making the tooth un-restorable, perforations, a fractured tooth, curved or hardened canals, and extra canals whose presence couldn’t be diagnosed earlier leading to persistent pain and infection. I understand that root canal files are extremely fragile instruments and may sometimes separate within the root, which may or may not affect success. Teeth exhibiting extensive infection where conventional root canal therapy is not enough and might need further surgery or treatment by a specialist at additional costs to me. A small percentage of root canals fail despite the best efforts. I understand that specialty care may be indicated if complications arise and any costs incurred are my responsibility. After root canal therapy, a crown is usually needed which, if not placed right away, might lead to fracture of the tooth and possible extraction.
_____ 10. CHANGES IN TREATMENT PLAN:
I understand that during treatment it may be necessary to change or add procedures because of conditions discovered during treatment that were not evident during examination. I authorize my doctor to use professional judgment to provide appropriate care.
I understand that dentistry is not an exact science and that no specific results can be assured or guaranteed. I acknowledge that no such guarantees have been made regarding dental treatment I have authorized. I understand that the treatment plan and fees proposed are subject to modification, depending upon unforeseen or undiagnosed conditions that may be recognized only during the course of treatment. CONSENT: I have had the opportunity to have all my questions answered by my doctor and I certify that I understand English. My signature below signifies that I understand the treatment and anesthesia that is proposed for me, together with the known risks and complications associated with that treatment. I hereby give my consent for the treatment I have chosen.
PROSPER DENTISTRY & ORTHODONTICS
Written Financial Policy Thank you for choosing Prosper Dentistry and Orthodontics. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
-Cash, Check, Visa, MasterCard, Discover Card, or American Express
We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care.
-Payment Plans with CareCredit
-Allow you to pay overtime with NO INTEREST
-Convenient, low monthly payment plans also available
-No annual fees or pre-payment penalties
Prosper Dentistry and Orthodontics requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.
For plans requiring multiple appointments, alternative payment arrangements may be provided. For larger or comprehensive treatment plans, a $500.00 deposit is required to secure your appointment.
For patients with dental insurance we are happy to work with your carrier to maximize your benefit and bill them, however, your estimated portion is due at the time services are rendered. The patient is responsible for any balance due after insurance pays.
A fee of $25.00-$75.00 is charged for patients who no show or cancel more the 2 times in a calendar year without a 48-hour notice.
Prosper Dentistry and Orthodontics charges $35.00 for returned checks.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.