Patient Information Form

Medical Health History

Name

Phone

Physicians name

Phone

Have you been under special care of a medical doctor in the past two years?

Yes No

Are you currently taking any medications?

Yes No

If yes, please list those below; including the amount and frequency

Please check the following that apply.

Smoke

Use of chewing tobacco

Smoke cigarettes

How much?

If female, please answer the following:

Oral contraceptives

Pregnant # of weeks

(input your answer in the text box below.)

Nursing

Hormone Replacement Therapy

If pregnant, # of weeks

DENTAL HISTORY

Do you have anxiety about dental care?

Yes No

Current pain/discomfort in jaw, mouth, etc?

Yes No

Have you ever had injury to your face, jaw, or teeth?

Yes No

Have you ever had braces?

Yes No

Have you had your wisdom teeth extracted?

Yes No

Do you wear removable dentures?

Yes No

Do you use fluoride toothpaste?

Yes No

Do you use fluoride rinses?

Yes No

Have you ever taken fluoride supplements?

Yes No

Do you drink pop or sports drinks (like Gatorade)?

Yes No

Do you drink coffee?

Yes No

Do you have well water in your home?

Yes No

How long has it been since your last dental check-up?

Months

Years

Any additional information you would like to share?

I prefer a private setting with the doctor to discuss my Medical History form.

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my
medicines change, I will inform the doctor of dentistry at the next appointment without fail.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Signature of patient (parent/guardian)

For future use only

Please let us know at any time if you prefer a private setting to discuss changes with the doctor.

Are there any changes from the previous answers on this health history form?

Yes No

If yes, please describe

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Signature of patient (parent/guardian)

Are there any changes from the previous answers on this health history form?

Yes No

If yes, please describe

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Signature of patient (parent/guardian)

Are there any changes from the previous answers on this health history form?

Yes No

If yes, please describe

Date

Signature of patient (parent/guardian)

Financial Policy Agreement

Our goal is to help patients reach the highest level of oral health possible so they may enjoy the benefits of a comfortable, functional, and attractive smile.

PAYMENT POLICY

Payment is expected at the time of your dental treatment.

To assist our patients meeting their dental care needs, we offer several payment options:

Cash / Personal Check / Money Order
Credit Card: We accept Visa, MasterCard and Discover
CareCredit: A line of credit offered through a third-party financing service allows you and your family members dental care needs to be met in a timely manner. Payment to us is received as treatment is delivered. Based on qualification, monthly payments are made by you to CareCredit.

Please contact our business office prior to your scheduled appointment to discuss payment options. There will be a $25 return check fee assessed on all returned checks.

DENTAL BENEFIT PLANS (commonly referred to as “Dental Insurance”)

It is your responsibility to be informed about your dental benefit plan’s provisions and stipulations. Dental insurance coverage is a contract between you, your employer, and the thirdparty payer (plan carrier.) Our most important duty is to advise you and treat your dental care needs, without regard to what your benefit plan might “allow” or “cover.”

We try our best to assist our patients in understanding their recommended treatment, and help in investigating benefit plan coverage - to the extent we are able. However, with hundreds of companies, and different policies within each company, our office cannot know the benefits for each individual. We urge you to inform yourself of your coverage prior to any procedures. Your Human Resource department or your dental benefit carriers are good resources. We are not responsible for your benefit plan’s final determinations, changes in policy, or cancellation of coverage.

As a courtesy, we will gladly submit a dental claim for procedures performed at our office on your behalf to your benefit plan carrier using a standard ADA form. For us to provide this service, it is important that you provide accurate and up-to-date information. Please be prepared to present your insurance identification card at each visit. Additional administrative procedures required by your insurance carrier are your responsibility.

Your estimated co-pay amount is due at the time of service. This is an estimate, based on whatever information is known to us. Should your final benefit amount differ from the estimate, a balance may be due (or may be refunded.)

Reminder: Many insurance companies require pre-authorization or even second opinions. It is your responsibility to inform us prior to your appointment if a pre-authorization or a second opinion is required.

I have read and understand the above Financial Policy. Please read and initial policy below.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed

Date

CANCELLATION POLICY

We understand that at certain times it is necessary to change an appointment time. We require a 2 business days notice to change or cancel a scheduled appointment. A fee of $50.00 per hour may be assessed for a same day cancellation or if you do not show up for your scheduled appointment.

I have read and understand the above Cancellation Policy.

Initial

This financial statement is provided to notify you of our policies as of the date of signature.

Acknowledgment of Privacy Practices (HIPPA)

Patient Acknowledgement and Consent Form

Effective April 14, 2013, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA's requirements, we have displayed and made available for you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan Law requires us to first obtain your written acknowledgement and written consent prior to disclosing any of your information except for our disclosures in connection with; a defense to a claim challenging our professional competence; a review of entity's functions; a claim for payment of fees; a third party payer's examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Name

Date

Patient Acknowledgement

Please sign to acknowledgement that you have been made aware of our Notice of Privacy Practices.

I acknowledge that I may receive a copy of the Notice of Privacy Practices.

Signature of Patient or Parent/Legal Guardian

Input Patient or Parent/Legal Guardian Name

Patient Consent

Please sign to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information which you deem necessary in connection with my treatment.

I understand that the law does not require my consent for such disclosures of the type listed above.

Signature of Patient or Parent/Legal Guardian

Input Patient or Parent/Legal Guardian Name

Patient Special Request

I do not want you to disclose patient information with the person(s) listed below:

Parent(s) or Legal Guardian

Fill out the details

Spouse

Fill out the details

Other

Fill out the details

Signature of Patient or Parent/Legal Guardian

Input Patient or Parent/Legal Guardian Name

By typing your name and signature above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.