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- Theresa Mabel Newman
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1 PATIENT INFORMATION Patient's name Preferred name Male Female If minor, responsible party name Mailing address City State Zip Social Security Number Birth date Home phone Work phone Cell phone Employer Occupation Marital Status Single Married Divorced Widowed Separated Domestic Partner Spouse's name Spouse's employer How did you hear about our office? BILLING, CREDIT, AND BILLING INFORMATION (Please fill out completely) Subscriber Name Relationship to Patient Subscriber DOB SSN/ID Subscriber Employer Insurance Company Name Group Number SECONDARY INSURANCE (If applicable) Subscriber Name Relationship to Patient Subscriber DOB SSN/ID Subscriber Employer Insurance Company Name Group Number RELEASE I authorize Dr. Worrell to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child s) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental or medical care payor. I understand that I am financially responsible for payment in full of all accounts. Finance charges of 1% monthly will be applied to balances due over 90 days (per RCW 19.52) SIGNATURE OF PATIENT/GUARDIAN DATE
2 MEDICAL HEALTH HISTORY Patient s Name DOB Are you under a physician s care now? Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? Are you taking any medications, pills, or drugs? Do you take, or have taken, Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or any Other medications containing bisphosphonates? Do you use tobacco? Women: Are you Yes No Pregnant/Trying to get pregnant? Nursing Taking oral contraceptives Are you allergic to any of the following? Asprin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Other? Do you use controlled substances? Yes No If yes Do you have or have you had any of the following? (PLEASE CHECK ANY THAT APPLY) AIDS/HIV Positive Alzheimer s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Nearest Relative not living with you: Diabetes Drug Addiction Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Headaches Glaucoma Hay fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis High Blood Pressure High Cholesterol Hypoglycemia Name Relationship Phone Do you have any disease, condition, or problem not listed above? Kidney Problems Liver Disease Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Stomach/Intestinal Disease Stroke Thyroid Problems Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Signature of patient (or parent)
3 DENTAL HISTORY How may we help you today? Your current dental health is: Good Fair Poor Do you require antibiotics before dental treatment? Yes No Are you currently in pain? Yes No Have you ever had gum treatment? Yes No Do you now or have you had any pain/discomfort in your jaw joint? (TMJ) Yes No Are you under stress? (New Job, Moving, Relationships) Yes No Do you like your smile? Yes No Is there anything you would like to change about your smile? Yes No Are you happy with the color of your teeth? Yes No Do your gums bleed? Yes No How many times do you: Floss/week? Brush/day? Are your teeth sensitive to heat, cold or anything else? Yes No Have you lost any teeth? Yes No Have you ever had any unfavorable dental experiences? Yes No When was your last dental cleaning? When was your last dental visit? Why did you leave your previous dentist? How can we accommodate you better during your dental visit? Here at WEDental, we offer a wide variety of services to enhance and keep your smile beautiful. Please circle any services below you would like our friendly staff to discuss with you during your visit. Teeth Whitening Traditional Orthodontics Invisalign Partials/Dentures Veneers/Lumineers Smile Makeover Sealants Bonding Crowns Night/Sport Guards
4 FINANCIAL POLICY In the interest of good communication and our continued commitment to provide the highest quality of dental care available to all of our patients, we have established a Patient Financial Policy. It is our hope that this policy will facilitate open communication between us and help avoid potential misunderstandings, allowing you to always make the best choices related to your care. We are committed to support you in understanding your dental health, and will always present you with the best dental solution possible to treat your personal situation. To make these services comfortably affordable we are pleased to offer you the following payment options. Cash, Check Visa, MasterCard, Discover, AMEX CareCredit (Financing) We will, as a courtesy, process your insurance benefits in our office. All questions regarding your insurance benefits must be addressed to your insurance carrier. I agree that I am fully responsible for the total payment of all procedures performed in this office this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that any estimated portion, not covered by insurance, is due at time of service for all services rendered. I understand that all services are due to be paid within ninety (90) days of date of service, regardless of whether or not my insurance benefits have been received. One percent (1%) per month interest, twelve percent (12%) per year will be charged on accounts 90 days from treatment date (per RCW 19.52). I also understand that should credit be extended to me by this dental office, a credit check will be made through WEDental or other credit services and I authorize release of all financial data. Please make your questions and concerns known to our Accounts Manager who is happy to discuss this policy and ensure that you have an outstanding experience. Signature of Patient/Guardian CANCELLATION, MISSED APPOINTMENT POLICY Our office is designed to give each individual our personalized care, as a courtesy we do ask that if you need to change an appointment time that you give us 48 hours advanced notice so that we may give that time to someone else in need. An appointment is considered broken for one or more of the following reasons: 1. Failure to show up for a scheduled appointment 2. Canceling an appointment without giving 48 hour notice 3. Showing up more than 15 minutes late for an appointment. The broken appointment fee is $50.00 per patient, as it is difficult to fill our schedule on a last minute basis. By signing the agreement I understand the policy as defined above and agree to abide by it. Signature of Patient/Guardian
5 ACKNOWLEDGEMENT OF STATEMENT OF PRIVACY PRACTICES I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of WEDental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. WEDental reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. ADDITIONAL DISCLOSURE AUTHORITY In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. (I understand that the default answer is NO. Without indicating YES in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPPA rules) ANY MEMBER OF MY IMMEDIATE FAMILY YES NO SPOUSE ONLY YES NO OTHER (PLEASE SPECIFY): YES NO Printed name of Patient or Personal Representative Signature of Patient or Personal Representative Description of Personal Representative s Authority OFFICE USE ONLY BELOW THIS LINE RECORD OF ACKNOWLEDGEMENT NOT OBTAINED PROVIDED PRIOR TO TREATMENT? YES NO DATE PROVIDED: REASON FOR DENIAL: NEEDED MORE TIME TO REVIEW STATEMENT OF PRIVACY PRACTICES? WANTED TO CONSULT WITH ANOTHER PERSON, BEFORE SIGNING. UNABLE TO SIGN. REASON NOT GIVEN. OTHER (EXPLAIN):
Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
PATIENT REGISTRATION. First Name: Middle Initial: Last Name: Home Phone: Work Phone:
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address City, State, Zip: Home Phone: Work Phone: Cell Phone: Birth Date: Age: Sex: Male Female Soc. Sec. #: Occupation: Employer: Marital Status:
CONSENT FOR TREATMENT
PATIENT INFORMATION PERSON FINANCIALLY RESPONSIBLE LAST NAME FIRST M.I. NAME RELATIONSHIP TO PATIENT PREFERS TO BE CALLED BY MALE FEMALE BIRTH DATE SOCIAL SECURITY NO. BIRTH DATE SOCIAL SECURITY NO. ADDRESS
Office Hours: Monday - Thursday 8:00 A.M. 5:00 P.M. New Patient Exams & Cleanings:
We want to provide you with the best dental care possible in an efficient and timely manner. Please take a moment to review our office policies to help us achieve our goals in serving you. If you are a
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Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
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Name: Phone: Ins. Co: Group #: ID# Phone #: Name of Insured: Relationship to patient: SS#: / / DOB: / / Employer: Phone:
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NEW PATIENT WELCOME PACKET PATIENT INFORMATION
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WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
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