Guardian/Patient Name. Family Dental Care NC Country Club Rd---Jacksonville, NC Telephone: (910) SIGNATURE ON FILE

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1 Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC Telephone: (910) Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions. I authorize release of information to all my Insurance Companies. I understand that I am responsible for my bill. I authorize my doctor to act as my agent in helping me obtain payment from my Insurance Companies. I authorize payment directly to my doctor. I permit a copy of this authorization to be used in place of the original. My signature also applies to the dependents listed below(if applicable) Dependent s Name Birthdate College Signature Date

2 Family Dental Care NC 1701 Country Club Road Jacksonville, NC Date: Patient s Name: DOB: Age: SSN: Marital Status: Sex: Address: City: State: Zip: Home Phone: Cell Phone: Patients Employer: Work Phone: INSURANCE COVERAGE: Yes No Name of Dental Insurance: Sponsor s Name: Sponsor s Employer Phone: Sponsor s SSN: DOB: Group Number: How did you hear about us? MEDICAL HISTORY If yes Are you under a physician s care now? Yes No Have you ever been hospitalized or had a major operation? Yes No Have you ever had a serious head or neck injury? Yes No Do you take or have you taken Phen-Fen or Redux? Yes No Have you had trouble with previous dental treatment? Yes No Are you on a special Diet? Yes No Do you use tobacco? Yes No How many per day? Do you drink alcohol? Yes No How many per week? Are you currently taking any medications? Yes No ARE YOU ALLERGIC TO ANY OF THE FOLLOWING? Aspirin Penicillin Codeine Acrylic Local Anesthesia Amoxicillin Sulfa Drugs Iodine Metal Sedative Latex Erythromycin Other? PLEASE CHECK ALL CONDITIONS THAT APPLY TO YOU AIDS/ HIV Anemia Artificial Heart Valve Artificial Joint Asthma/ Hay Fever Blood Disease Breathing Problems Cancer Chemotherapy Chest Pains Cold Sores Diabetes Drug Addiction Epilepsy/ Seizures Excessive Bleeding Excessive Thirst Fainting/ Nervous Spells/Dizziness Frequent Cough Frequent Headaches Heart Attack/ Failure Heart Murmur Heart Pacemaker Heart Trouble/ Disease Hepatitis A Herpes High Blood Pressure Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Pace Maker Radiation Treatments Recent Weight Loss Rheumatism Sinus Trouble Stroke Thyroid Disease TMJ/ Joint Clicking Ulcers Venereal Disease WOMEN: Are you now pregnant? Trying? Nursing? Taking Birth Control? The above information is true and complete to the best of my knowledge. I agree to pay any and all charges not covered by my dental insurance. Patient/ Guardian Signature: Date:

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5 Family Dental Care NC Michael Williams D.D.S James Wilson D.M.D 1701 Country Club Road Jacksonville, NC (910) ACKNOWLEDGEMENT OF RECIEPT I acknowledge that I received a copy of Dr. Michael Williams Notice of Privacy Practices. Patient Name: Signature: Date:

6 Family Dental Care NC Michael Williams D.D.S James Wilson D.M.D 1701 Country Club Road Jacksonville, NC (910) Patient Name: Date of Birth: I give Dr. Michael Williams and Dr. James Wilson and/or staff permission to discuss/release my Medical/Dental information to the following person/person s: Name: Relationship: Name: Relationship: Patient Signature: Date: Witness: Date:

7 Family Dental Care NC Michael Williams D.D.S James Wilson D.M.D 1701 Country Club Road Jacksonville, NC (910) PATIENT S NAME: AGE: ADDRESS: CITY: STATE: ZIP: CELL: WORK: I hereby give my consent to Dr. Michael Williams, Dr. James Wilson, their associates, assistants, and/or hygienist to do an oral examination and take whatever X-Rays that are deemed necessary to make a full and compete diagnosis for my dental treatment, and/or any other procedure related to my oral hygiene. PATIENT/GUARDIAN SIGNATURE: DATE: The necessary treatment has been diagnosed and explained to me. I agree to the use of a local anesthetic, sedation, and analgesia depending on the judgment of the dentist involved in my treatment. I have been informed of any advantages and disadvantaged of the treatment discussed. (In case patient is a minor, I refers to the patient or guardian) PATIENT/ GUARDIAN SIGNATURE: DATE: The Doctor is not responsible for the completion of treatment if I consistently fail to keep scheduled appointments. INITIALS

8 FAMILY DENTAL CARE NC Appointment Policy Agreement Family Dental Care is dedicated to your quality care and is pleased to reserve your appointment time exclusively for you. We attempt to schedule appointments that are most convenient for you and that fit your personal schedule. We respect our patient time and make every effort to remain on schedule. Some visits are more complicated than initially anticipated, and emergencies may arise that could possibly delay us. In such a case, every effort will be made to notify you beforehand. Because we reserve time exclusively for each patient, we ask that you make every effort to not change your reserved dental appointment. If you cannot keep your scheduled appointment, we require a minimum 24 hour notification. This allows your reserved time to be made available for other patients in need of treatment. To notify us of any change, please call our office during business hours. It is our policy that if you do need to change an appointment, that you to call and speak directly with a staff member as our answering service does not accept changes or cancellations. We understand that there are unforeseen circumstances that cause reserved appointments to be missed without 24 hours notice; we certainly want to make provisions for this within our policy. In order to make this provision, as well as to maintain the most efficient schedule for all our patients, our Appointment policy is as follows: As a courtesy, our staff attempts to confirm appointments two weeks before the scheduled date and time by method of text and . If we do not hear from you, we will call you two days before the reserved time. Late arrivals cause schedule delays for those patients who arrive promptly at their appointment time. Late arrivals will be worked into the schedule if time permits or re-appointed to another day. Patients who DO NOT SHOW for their appointment or reschedule without the required 24 hours notice will be charged a minimum of $30.00 per half hour scheduled. THIS WILL GO INTO EFFECT ON JANUARY 1, To avoid raising our dental fees and allow for all of our patients to reserve appointment times when desired, we find it necessary to implement this policy. We are committed to your oral health and your scheduled appointments allow us to be partners in your Dental Care. Thank you for understanding and respecting our time policy. By signing this policy I understand that I must give at a minimum of 24 hours notice to cancel or reschedule an appointment or I will be charged a missed appointment fee. SIGNATURE DATE

9 FAMILY DENTAL CARE NC Financial Policy Agreement We would like our patients to be informed of our office financial policy. We are committed to providing you with the best possible care. If you have dental benefits, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy. We base our fees on our Quality, Expertise, Time and Service. We clearly list and explain all of our fees during your treatment consultation. After your treatment plan is formulated, we will provide you with a written ESTIMATE of what your financial obligation will be. To make your payment more convenient for you, we accept cash, personal checks, Visa, MasterCard, and Discover. In addition we offer an excellent third party financial payment plan through Care Credit. Any portion of an account balance beyond 60 days incurs a service charge of 1.5% per month. Returned checks incur a handling fee of $ We encourage anyone having temporary financial problems to contact us immediately so we can assist you in the management of your account. Any account that is 90 Days overdue will be turned in to the Collections Attorney. Our primary concern is your complete oral health. Nonetheless, we will be sensitive to your financial circumstances within the framework of sound business practices. If you have any questions about the above information, please do not hesitate to ask us. FINANCIAL ARRANGEMENT OPTIONS: OPTION 1: Cash or Check, This option is only available for those who do not have any insurance that will be filed. Appointment must be paid in full and a 15% discount will be applied to the total. OPTION 2: Cash, Check, Visa, MasterCard, Discover and Care Credit (we do offer Interest Free Plans with Care Credit) for your ESTIMATED CO-PAY along with any Deductibles are due at the time services are rendered. We will file insurance claim for patient. OPTION 3: For Services that are over $700 we are able to break into three payments with leaving a Credit Card on file and the first payment will be the day that the services are rendered. We will make a copy of the Card and have patient sign the agreement of the dates that we will be ringing the card out on. In the event the card comes back declined on one of the agreed dates the account will be turned over to the Collections Attorney immediately. FOR PROFESSIONAL SERVICES, I AGREE TO PAY THE TREATMENT FEE ACCORDING TO OPTION #

10 A Word About Dental Insurance If you have dental benefits, you must bring proof of benefits and our accounting team will be more than happy to prepare all of the necessary forms for this important benefit. If you were not issued a card please be prepared to bring in the following information. Insurance carrier name, claims mailing address and phone number Group/Plan number Subscriber name and birth date Subscriber ID Number/SS# However, we remind you that your insurance is a contract between you, your employer and the insurance company, not between your insurance company and our office. We can make no guarantee of any estimated coverage, but we will do our best to see that you receive your maximum benefits. Your bill is ultimately your responsibility should insurance not cover the expected amount due, or if you re insurance fails to pay us. Please keep in mind that your responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Not all services are covered by benefits in all contracts and some companies arbitrarily select certain services they will not cover. I understand that I am responsible for the total investment and I agree to all the terms and conditions of this agreement. I also understand that if I do not honor the financial arrangements as I agreed above, that the Doctor has the option to discontinue further treatment until the matter can be resolved. I understand that I take total responsibility for payment for these services and agree to pay according to the terms as described above. PATIENT/GUARDIAN SIGNATURE DATE Cosmetic Dentistry and Insurance Cosmetic Procedures are generally not covered by most dental insurance policies: however, partial benefits are sometimes available if the teeth are broken or have previous dental fillings or crowns.

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