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Patient's First Name *

Patient's Middle Name

Patients Last Name *

Home Phone

Mobile Phone *

Receive SMS (yes / no)

Gender *

Email Address *

Social Security Number#

Date of birth *

Address *

City *

State

Zip *

Marital Status

If you are completing this form on behalf of other person. Please enter your name and relationship with that person

Primary Dental Insurance Carrier

Insurance Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Subscriber’s Name

Subscriber’s Date of Birth

Subscriber ID #

Patient’s Relationship to Subscriber

Group Number

Subscriber’s Employer

How did you hear about Smile Care Family Dental

Preferred Contact Method

Agree

By providing my phone number, I consent to receive SMS text messages from Smile Care Family Dental for appointment reminders, general two-way communication and marketing messages. Msg frequency varies. Msg & Data rates may apply. Reply HELP for support. Reply Stop to opt out.

Health History

Patient's First Name *

Patient's Last Name *

Date of birth

Dental Information

For the following questions, please check Yes or No

Do your gums bleed when you brush or floss?YesNo

Are your teeth sensitive to cold, hot, sweets or pressure?YesNo

Does food or floss catch between your teeth?YesNo

Is your mouth dry?YesNo

Do you have an unpleasant taste or odor?YesNo

Do you smoke or use Tobacco products?YesNo

How many times a day do you brush your teeth?

How many times a day do you floss your teeth?

Have you ever had any problems associated with previous dental treatment?YesNo

Has the fear of discomfort kept you from regular dental visits?YesNo

Are you currently experiencing dental pain or discomfort?YesNo

How long has it been since last complete examination with a full series of x-rays?

How do you feel about your smile?

What prompted you to seek dental care at this time?

What makes you unhappy about your smile?

Are you interested in teeth whitening?

Are you interested in straightening your teeth?

Are you concerned with the cost of maintaining your oral health?

What are the challenges you face in maintaining good oral health?

Do you have earaches or neck pains?YesNo

Do you have any clicking, popping or discomfort in the jaw?YesNo

Do you grind your teeth?YesNo

Do you have any sores or ulcers in your mouth?YesNo

Do you wear dentures or partials?YesNo

Have you ever had a serious injury to your head or mouth?YesNo

Medical Information

Are you currently under the care of a physician?YesNo

If Yes, reason:

Are you in good health?YesNo

Has there been any change in your general health within the past year?YesNo

If Yes, reason:

Date of last physical exam?

Have you had any Orthopedic Joint Replacements? (Hip, Knee, Finger, Etc.)YesNo

If Yes, Explain:

Physician Name

Phone:

Street Address

Have you had a serious illness, operation or been hospitalized in the past 5 years?YesNo

If Yes, Explain:

Please List all Medication You Are Taking

Do You have any Drug Allergies?YesNo

Local AnestheticsYesNo

AspirinYesNo

Penicillin or other AntibioticsYesNo

Barbiturates, Sedatives, or Sleeping PillsYesNo

Sulfa DrugsYesNo

Codeine or Other NarcoticsYesNo

Latex (rubber)YesNo

IodineYesNo

Hay Fever / SeasonalYesNo

FoodYesNo

OtherYesNo

If selected other, please mention

Females: Are you currently pregnant?YesNo

Please indicate if you have or have not had any of the following diseases or problems:

Autoimmune diseaseYesNo

Rheumatoid ArthritisYesNo

Systemic Lupus ErythematosusYesNo

AsthmaYesNo

BronchitisYesNo

EmphysemaYesNo

Sinus TroubleYesNo

TuberculosisYesNo

Cancer / ChemotherapyYesNo

Radiation TreatmentYesNo

Chest Pain upon exertionYesNo

Chronic PainYesNo

Diabetes: Type I or IIYesNo

Eating DisorderYesNo

Gastrointestinal DiseaseYesNo

G. E. Reflux/Persistent HeartburnYesNo

UlcersYesNo

Thyroid ProblemsYesNo

GlaucomaYesNo

StrokeYesNo

Hepatitis, Jaundice or Liver diseaseYesNo

EpilepsyYesNo

Fainting sSpells or SeizuresYesNo

Abnormal BleedingYesNo

PacemakerYesNo

Mitral Valve ProlapseYesNo

ArthritisYesNo

High Blood PressureYesNo

Low Blood PressureYesNo

Severe Headaches / MigrainesYesNo

Unrepaired, cyanotic CHDYesNo

Repaired (completely) in last 6 MonthsYesNo

Congenital Heart Disease (CHD)YesNo

Damage Vales in transplanted heartYesNo

Previous infective endocarditisYesNo

Artificial (prosthetic) Heart valveYesNo

AIDS or HIVYesNo

AnemiaYesNo

Rheumatic FeverYesNo

Heart MurmurYesNo

Heart AttackYesNo

Damaged Hear ValvesYesNo

Congestive Heart FailureYesNo

ArteriosclerosisYesNo

AnginaYesNo

Cardiovascular DiseaseYesNo

Sexually Transmitted DiseaseYesNo

Kidney ProblemYesNo

If Yes, Explain

Neurological DisordersYesNo

If Yes, Explain

Mental Health DisordersYesNo

If Yes, Explain

Other Congenital Heart DefectsYesNo

If Yes, Explain

Blood TransfusionYesNo

If Yes, Date

Has a Physician or previous Dentist recommended that you take antibiotics prior to your dental treatment?YesNo

If Yes, Name of Physician or Dentist making recommendation

Phone

Do you have any disease, condition, or problem not listed above that you think should be notated or discussed?

Note: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Date *

Signature *

Comments By Dentist:

Dentist Signature : _________________ Date : _________________

CONSENT FOR SERVICES

Patient First Name *

Patient Last Name *

Date of birth *

As a condition of your treatment by this office, financial arrangements must be made in advance.

All co-payments are due at the time services are rendered.

Any emergency and/or after hours dental services are subject to additional fees.

Patients who carry dental insurance understand that payment for all services furnished are ultimately their responsibility. Insurance does not guarantee payment and we cannot receive any guarantee of payment. This office cannot render services on the assumption that our charges will be paid by an insurance company. As a courtesy to our patients, we will prepare and submit dental claims and assist in making collections from insurance companies. Any such collections will be credited to the patient's account and any resulting balance is the patient responsibility.

In this office we believe in providing our patients with the highest standard of care. This means using the best materials available in order to promote and preserve a healthy smile. We understand that your dental insurance may downgrade to amalgam (metal) fillings, however it is not standard of care today and we do not recommend the use of them.

X-rays and Photographs:

I authorize Smile Dentist of Chester Springs(DOCS), the doctor and team to take any x-rays and photographs deemed necessary for the detection and diagnosis of oral diseases. I authorize the release of this and any other information to my insurance company necessary for processing my dental claim (if applicable and according to HIPAA regulations).

Appointment Policy:

If you find it impossible to keep an appointment, for consideration of other patient's needs, we ask for 48-hour notice, please.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay for services at the time they are rendered or within 5 days of billing, if credit is extended at the discretion of the practice. Outstanding balances may be subject to additional charges. I further agree to pay all costs and reasonable attorney fees if my account has to be turned over to a third-party collection agency.

OptionBy checking here and signing below, I acknowledge that i have read and agree to the above terms and conditions

Signature

Date *

Responsible Party - Relationship to Patient *

PATIENT FINANCIAL AGREEMENT

Thank you for choosing Smile care family dental as your dental provider. We are committed to providing you with the highest quality dental care using only the best material and technology available on the market today. We are also committed to providing you with up to date information and educational tools so that you may fully participate in your oral health care decisions.

Please understand that payment of your bill is part of this treatment and care. Any unpaid insurance balance older than 30 days is the patient’s responsibility. Uninsured patients are expected to pay in full, at the time of service.

For your convenience, we have answered a variety of commonly asked financial policy questions below. If you need further information regarding these policies, please ask to speak with the office manager.

Q&A

What Forms of Payment are Accepted?

We accept cash, personal check, VISA, MasterCard, AMEX, Discover, Care Credit and Enhanced Patient Financing.

Which Insurance Plans Do You Contract With?

Smile Care Family Dental accepts most major PPO dental insurance plans. Please remember that your insurance policy is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benefit under your policy. We do expect patients to be interactive and responsible for communicating with their insurance carrier on any open claims. It is your responsibility to verify that the facility is in network and a participating provider with your plan. A current provider listing should be made available to you by your employer, insurance company or insurance website. You can verify with Our Staff by providing insurance details, Our staff can help to find your eligibility and benefits summary.

What is My Financial Responsibility for Services Rendered?

You are responsible to make payment in full at the time of service if you are not insured. Our insured patient’s are expected to pay their estimated out of pocket portion at time of service. Your estimated portion may be adjusted after the time of service contingent upon final reconciliation of insurance payments.

What Documents Must I Supply?

Our office requires that you supply a photo ID as well as your insurance card and/or social security number for verification of benefits. You are further required to update our office in a timely fashion of any changes to your personal information including but not limited to, name change, mailing address, insured party change (guarantor), loss of or change in employment or change in insurance coverage.

What are My Options for Financial Assistance if I Do Not Have Dental Insurance?

Our office is proud to offer a Patient DOCS Loyalty Plan! This plan is exclusive to Smile Care Family Dentaland is not insurance coverage. It is designed to provide you with the opportunity to maintain your oral health without the worries and stress of overwhelming financial burdens. This plan covers two free exams, cleanings and x-rays annually, as well as discounted pricing on most our services. Please ask one of our team members for more information on how this option might benefit you!

Additional Information…

Our office does not use amalgam (silver in color) for restorations. We understand that patients want and prefer tooth-colored fillings. Most insurance companies “down grade” this service; your estimated out of pocket for fillings may differ from what was paid upfront. Any amounts passed on to you by your insurance, that was not collected at the time of service, will be billed to you by mail.

Our office makes the best effort to guide you through the insurance billing and collection process.

Unfortunately, it is unreasonable to expect that we will know all the details for every employer plan.

Non-Payment on Account-An account with an unpaid balance is subject to third party collection agency intervention. Should such an event be required, you will be charged an additional $50.00 collection fee.Smile care family dentalhas the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. If your account is referred to a collection agency, attorney or court, the past due status may be reported to credit reporting agencies and could have an adverse effect on your credit history. Failure to comply with our financial policies may also result in withdrawal of care.

Returned Check-An account with a returned check (bounced) will have an additional $50.00 fee added to the balance.

I have read and fully understand my financial obligations

Date *

Signature *

Signee FirstName *

Signee Last Name *

Relationship to Patient

Phone

Mailing Address

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Purpose:

This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

OptionBy checking here and signing below, I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.

Patient First Name *

Patient Last Name *

Date of birth *

Date *

Signature *

Authorization to Release Information

Purpose:

This form is used to obtain authorization to release information regarding you covered under the Privacy Act to people other than yourself

I, authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself.

Name

Relationship

Name

Relationship

For Office Use Only:

We attempted to obtain written acknowledgement of receipt of our Notice Practices, but acknowledgement could not be obtained because:
( ) Individual refused to sign
( ) Communications barriers prohibited obtaining the acknowledgement
( ) An emergency situation prevented us from obtaining acknowledgement
( ) Other (Please specify)______________________________________________ Signature : _____________________________ Date : _______________________

For Office Use Only: We attempted to obtain written acknowledgement of receipt of our Notice Practices, but acknowledgement could not be obtained because: ( ) Individual refused to sign ( ) Communications barriers prohibited obtaining the acknowledgement ( ) An emergency situation prevented us from obtaining acknowledgement ( ) Other (Please specify)______________________________________________ Signature : _____________________________ Date : _______________________

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