Hip or knee joint replacement Asthma/TB/lung disease/Emphysema Blood disease/anemia
Bisphosphonate drug treatments Venereal disease Thyroid disease
Tumors, growths, cancer HIV/AIDS Arthritis/rheumatism
High or low blood pressure Drug or alcohol dependency Diabetes
Use this space or write on back for any additional information or explanations:_________________
DENTAL HEALTH INFORMATION
What is the reason for your visit today? _________________________________________________
Last dental visit:_____________ Last dental cleaning:_________________ Last x-rays:__________
What was done at your last dental visit? _________________________________________________
Previous Dentist: Name:______________________________________________________________
Address:__________________ State:______Zip: _________Telephone:________
How often do you brush your teeth?___________ How often do you floss? ____________________
Do you have any dental problems now? Yes/ No
If YES, please describe______________________________
I have answered the aforementioned health questions to the very best of my knowledge. I will advise Dr. Ming Truong or the dental staff of any changes in my health history. I give this dental office consent to release my health information and x-rays relevant to my treatment to my insurance carriers, physicians or dental specialists that I may be referred to. Signature______________________________________Date____________________________
We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.
PAYMENT POLICY:Please be prepared for any deductible, co-pay, or other expenses at the time of service.Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. For your convenience, we accept the following forms of payment: cash, check, credit cards, and zero to low interest third-party financing through CareCredit.
DENTAL INSURANCE: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage. As a courtesy, we will file your dental insurance claim for you and accept assignment of payment. Some insurance companies recommend a pre-treatment authorization for the dental treatment to be provided. We will attempt to estimate any expenses prior to your visit to our office.
If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.
APPOINTMENTS & CANCELLATION POLICY: We reserve an appointment on the schedule for each patient procedure and are diligent about being on-time. Because of this courtesy, when a patient cancels an appointment, it impacts the overall quality of service we are able to provide. To maintain the utmost service and care, we request a 24-hour notice to reschedule an appointment. If you do not show up to a scheduled appointment, there will be a fee of $50 and a deposit to reserve the appointment time again, may be required. To serve all of our patients in a timely manner, we may need to reschedule an appointment if a patient is fifteen minutes late or more arriving to our practice. To reschedule an appointment due to late arrival, a fee of $50 or deposit to reserve the appointment time again, may be required.
E-MAIL COMMUNICATION: Our office uses email for non-urgent communication with our patients including appointment reminders. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by, unauthorized third parties. We will use the minimum necessary amount of protected health information in any communication.
I understand that the information I have given today is correct to the best of my knowledge. ___(initial)
I have read the above and agree to the financial and scheduling terms. ___(initial)
I authorize the release of information necessary to process my dental benefit claims. I hereby authorize payment directly to Dr. Ming Truong for dental services otherwise payable to me. ____(initial)
I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices has been made available to me. (separate enclosure) I have been given the opportunity to ask any questions I may have regarding this Notice. ___(initial)
I hereby acknowledge that a copy of this practice’s Dental Materials Fact Sheet has been made available to me. (separate enclosure) I have been given the opportunity to ask any questions I may have regarding this Fact Sheet.___(initial)