Trinity Dental Phone: S. Main Street, Kendallville, IN PATIENT INFORMATION

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1 Trinity Dental Phone: S. Main Street, Kendallville, IN PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don t hesitate to ask. Patient name /Preferred name Date of Birth Age Sex Married/Single/Widow/Divorced Home Address City State Zip Billing Address City State Zip Home Phone Cell Text Y N Preferred Contact Method Home Phone Cell Phone Text Work Mail Do not call Home Phone Cell Phone Text Work Mail Driver s license# State SS# of Patient Employer/Occupation Bus Phone Spouse s name (Parent if minor) Emergency Phone# (other than spouse) Primary dental insurance Group# Secondary dental insurance Group# Subscriber s name DOB SS# Name of previous Dentist Date of last visit Have you been out the United States in the last 21 days. Yes No Referred to us by See Notes

2 DENTAL HEALTH HISTORY Are you apprehensive about dental treatment? Y N How often do you brush? Have you had problems with previous dental treatment Y N How often do you floss? Do you gag easily? Y N Does your jaw make noise so that it bothers you Y N Does food catch between your teeth? Y N Do you clench or grind your jaws frequently Y N Do you have difficulty in chewing your food? Y N Do your jaws ever feel tired? Y N Do you chew on only one side of your mouth? Y N Does it hurt when you chew or open wide to take a bite? Y N Do you avoid brushing any part of your mouth? Y N Do you have earaches or pain in front of the ears? Y N Do your gums bleed easily? Y N Do you have any jaw symptoms or headaches upon awaking? Y N Do your gums bleed when you floss? Y N Does jaw pain or discomfort affect your appetite, sleep? Y N Have you ever noticed slow-healing sores mouth? Y N routine, or other activities? Y N Do you find jaw pain or discomfort extremely frustrated or Are your teeth sensitive? Y N depressing? Y N Do you feel twinges of pain when your teeth come in Y N Do you take medications or pills for pain or discomfort Do you take fluoride supplements? Y N (pain relievers, muscle relaxants, antidepressants) Y N Do want complete dental care Y N Do you have a temporomandibular (jaw) disorder(tmd) Y N Are you dissatisfied with the appearance of your teeth? Y N Do you have pain in the face, cheeks, jaws, joints, throat, or temples? Y N Are you unable to open your mouth as fast as you want? Y N Are you a habitual gum chewer? Y N Are you aware of an uncomfortable bite? Y N Have you had a blow to the jaw (trauma)? Y N

3 MEDICAL HEALTH HISTORY Do you have, or have you had any of the following Heart Problems Diabetes Y N Chest pain Y N Family history of diabetes Y N Blood pressure problem Y N Thirsty or mouth is dry much of the time Y N Shortness of breath Y N Heart murmur Y N Tuberculosis or other respiratory disease Y N Heart valve problem Y N Persistent cough or swollen glands Y N Artificial heart valve Y N Do you drink alcohol? Y N Rheumatic fever Y N If so how much? Pacemaker Y N Do you smoke? Y N If so, how much? Blood Problems Hepatitis, jaundice, or liver trouble Y N Easy bruising Y N Herpes or other STD Y N Frequent nosebleeds Y N HIV-positive/AIDS Y N Abnormal bleeding Y N Glaucoma Y N Blood disease (anemia) Y N Cancer/Tumor Y N Ever require a blood transfusion? Y N History of head injury? Y N Allergy Problems Epilepsy or other neurological disease? Y N Sinus problems Y N History of alcohol or drug abuse? Y N Skin rashes Y N Fainting spells, seizures or Epilepsy Y N Asthma Y N Frequent or severe headaches Y N Intestinal Problems Y N Thyroid Problems Y N Ulcers Y N Weight gain or loss Y N Bone or Joint Problems Special diet Y N Arthritis Y N Kidney or bladder problems Y N Back or neck pain Y N Women Premedication s required by physician Y N Are you Pregnant? Y N Physician Name Are you nursing? Y N Physician Phone

4 LIST ALL MEDICATIONS YOU ARE TAKING OR HAVE TAKEN IN THE LAST 12 MONTHS DO YOU HAVE ANY DISEASE CONDITION OR PROBLEMS NOT LISTED PREVIOUSLY THAT YOU FEEL WE SHOULD KNOW ABOUT? ARE YOU ALLERGIC TO ANY MEDICATIONS OR HAVE YOU REACTED ADVERSELY TO ANY MEDICATION? DENTIST NOTES Patient/Parent Signature Date Dentist Signature Date

5 GENERAL CONSENT I, consent to be a patient at the above named office and agree to a radiographic and clinical examination. I also understand and consent to the following: 1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures) implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. 2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history. 3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results. 4. I will pay in full any cost of treatment or insurance copayments according to the office s financial policy. I understand that even if insurance pre-estimate is given or a procedure has been preapproved, I am responsible for any costs that my insurance does not cover. 5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff. 6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about. Patient or Guardian Name Date Witness Date

6 FINANCIAL & APPOINTMENT POLICY Thank you for choosing us to provide your dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and forthright. Nowhere is that more important than in the area of finances. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our business office staff. I realize I am financially responsible for all charges incurred regardless of insurance coverage. DENTAL INSURANCE Patients are expected to pay for our services at the time they are rendered. Your insurance is a contract between you and your Insurance Company; therefore, all charges are your responsibility. As a courtesy to you we will complete your insurance form and submit it to the insurance company. Your estimated co-payment (the amount not covered by your insurance) for treatment is due at the time treatment is provided. If you fail to bring the required insurance information to your appointments we will ask that you pay the bill in full and be reimbursed from your insurance company with paperwork provided by our office. Our office does not guarantee that your insurance company will pay for the treatment you receive from our practice. If your claim is denied or the treatment is down-coded and or alternative benefits given, you will be responsible for paying the full balance amount left on the account at that time.. (please initial) I assign to Trinity Dental Dr. Tyrone Smith all Insurance benefits, if any otherwise payable to me for services rendered. I authorize and release information and payment of my dental benefits directly to the practice. Signature: We will mail medical insurance for you if all information is submitted to us in a timely manner and only 2 Dental Insurance Companies per patient. Our office will not enter into a dispute with your insurance company over any claim. Trinity Dental will provide the necessary documentation to your insurance company requests, to settle the claim. If your insurance company has not made payment within 60 days of billing, the balance will become your responsibility. Insurance coverage is a contractual agreement between the insurance company and you or your employer. We have no control over this relationship.

7 OPTIONAL PAYMENT POLICY Payments may be made using cash, check, Visa, MasterCard, Discover and American Express. Term Loans: Upon Application and approval we offer Care Credit and Citi Health Card, which are financing options that are available only for healthcare expenses. Terms of repayment differ depending on term selected. Payment in CASH Trinity Dental offers a 10% accounting courtesy for all services that are paid in full ON THE DAY SERVICES ARE PROVIDED OR STARTED. Payment by CHECK we offer a 5% accounting courtesy for all services that are paid in full ON THE DAY THE SERVICES ARE PROVIDED OR STARTED. MINOR PATIENTS The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit. OVERDUE BALANCE An account with an unpaid balance past 90 days will be sent to the collection agency. At that time you will be responsible for any and all costs incurred in the collection of your debt; an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt. APPOINTMENTS Patients must arrive at least minutes early for each appointment to update their health history, Insurance, Address, Etc. If you do not arrive for your appointment ON TIME you may need to reschedule as we try to maintain an efficient appointment system. We require at least a 24 hour notice for any cancelled appointments. After 2 missed appointments or cancelled appointment you will be either dismissed from the practice or only be appointed on a call in basis. PLEASE be considerate and inform us in advance if you need to change your appointment by phoning Please indicate your understanding and acceptance of these Financial and Appointment policies by signing below. I have read and fully understand my financial options and obligations. Additionally, by signing this form I authorize Trinity Dental to process credit card transactions initiated by me either by mail or phone and I authorize my credit institution to pay. Form Completed by: Signature of Patient and/or Legal Guardian Date In case of a child relationship to child: Relationship Date Are you the person legally responsible for this child? YES NO (Please circle one) Witness Date

8 Acknowledgement of Receipt of Notice of Privacy Practices Trinity Dental * You May Refuse to Sign This Acknowledgment* I have received a copy of this office s Notice of Privacy Practices. Print Name: Signature: Date: For Office Use Only _ We attempted to obtain written acknowledgement of receipt of our Notice of Privacy 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)

9 AUTHORIZATION FORM FOR USE OR DISCLOSURE OF PATIENT INFORMATION Patient Name: Patient's Date of Birth I hereby authorize the use and disclosure of the patient information as described below. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA Privacy regulations. I authorize the following person(s) may receive this patient information: Signature of Patient/Guardian Date

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