redrockdental.vegas - New Patient Form

Patient Information
Name:

First Name Middle Name Last Name
Preferred Name:
Soc. Sec. #
Birthday:

Month Day Year
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Sex:

Male Female
Home #:
Cell #:
Work #:
Email:
Marital Status:

Single Married Child
Occupation/School:
Employed by:
Whom may we thank for referring you?
Notify in case of emergency:
Phone #:
Insurance Information
Medical Insurance:
Subscriber Name:

First Name Middle Name Last Name
Subscriber SSN:
Birthday:

Month Day Year
Insurance Company:
Group Name:
Group #:
Member # or ID #:
Effective Date:

Month Day Year
Dental Insurance:
Subscriber Name:

First Name Middle Name Last Name
Subscriber SSN:
Birthday:

Month Day Year
Insurance Company:
Group Name:
Group #:
Member # or ID #:
Effective Date:

Month Day Year
Name of additional patients insured under these plans:
Authorization
We realize understanding your insurance coverage can be quite challenging. We do our best to verify your eligibility and benefits. This however is not a guarantee of benefits or payment from your insurance company. Unfortunately, detailed information is not always disclosed by your insurance company. We encourage you to become familiar with your policy’s exclusions, deductible, coinsurance, and frequency limitations. It is the patient’s responsibility to ensure correct and complete Insurance information is provided before or on the date they are to be seen. Please understand after your insurance processes your claim there may be a remaining balance left on your account that you will be responsible for.
I certify that I, and or my dependent(s) have insurance coverage and assign reimbursement all insurance benefits directly to Red RockDental and/or Summerlin Vision. I authorize the use of my signature on all insurance submissions and release all information necessaryto secure the payment of insurance benefits. I choose to pay for services at the time services are rendered in full and bill my own insurance. I do not have dental or vision insurance and will pay in full at the time services are rendered.
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by Drs. Alan & Civia McCaffrey to help determine appropriate treatment. If there is any change in my personal, insurance or medical status, I will inform Red Rock Dental and/or Summerlin Vision. By signing this I consent to treatment provided by Red Rock Dental and/or Summerlin Vision.
Signature:

Clear
Date:

Month Day Year
Dental History
Name:

First Name Middle Name Last Name
Preferred Name:
Date:

Month Day Year
Please describe the primary reason for your visit (concerns):
How long has this been going on and what would you like done?
If you could rate your smile from 1 – 10, what would it be?
Would you like to improve your smile?

Yes No
How?

Have you ever suffered from or been told you may have the following?

	Yes	No
Gum Disease
Bad Breath
Jaw Pain or TMJ
Dental Pain
Snoring/Stopped Breathing while sleeping
Bruxism or Grinding
Headaches or Migraines
Tooth Sensitivity to Hot or cold

Doctor’s Notes:
Health History
Primary Care Physician:
Phone #:
Date of last visit:

Month Day Year
Are you currently under physician care?

Yes No
Describe:
Have you ever used bis-phosphonate medication? (Fosamax, Actonel, Atelvia, Didronel, Zometa, Boniva)

Yes No
Check the box if you have any of the following: (Please check ‘No health concerns’ if no conditions apply.) *

No health concerns Circulatory Problems Herpes Rheumatic fever Abnormal bleeding Congenital heart disease High blood pressure Sexually transmitted disease Aids Cortisone treatment Jaundice Sinus trouble Anemia Diabetes Kidney disease Skin rash Arthritis/Rheumatism Emphysema Liver disease Stroke Artificial heart valve Epilepsy Low blood pressure Swollen feet or ankles Artificial Joints Fainting or dizziness Mitral valve prolapse Swollen neck glands Asthma Glaucoma Nervous problems Taking birth control Back problems Headaches/migraines Nursing Thyroid problems Blood disease Heart attack Pregnant Tonsillitis Cancer Heart murmur Psychiatric care Tuberculosis (TB) Chemical dependency Heart problems Radiation treatment Tumor or growth in head & neck Chemotherapy Hepatitis Respiratory disease Ulcers
Medications and Allergies
Currently taking any medications?

Yes No
If yes, list them:
Have you ever taken an antibiotic prior to dental treatment?

Yes No
Check the box if you have any of the following: (Please check ‘No known allergies’ if none apply.) *

No known allergies Latex Penicillin Codeine Local anesthetic Sulfa
Signature:

Clear
Date:

Month Day Year
Patient Name:

First Name Middle Name Last Name
Birthday:

Month Day Year
Short Notice Cancellation/Missed appointment Policy:
Initial
A short notice cancellation is any cancellation within 48 hours of appointment time.

We understand that occasionally circumstances arise that don’t allow you to be present for an appointment. We charge a $50 minimum fee for the first broken appointment, $100 minimum fee for the second broken appointment, and after the 3rd such instance, we may request you make arrangements to have your dental/optometric care with another office. Broken appointments may require pre-payment to reserve future appointments.
Insurance:
Initial
It is your responsibility to provide all necessary insurance eligibility, identification, authorization and referral information and to notify our office of any changes that may occur immediately. We require photo identification when accepting insurance information. It is the patients responsibility to know if our office is participating or non-participating with their insurance. Failure to provide all required information may necessitate patient payment in full for all services. When insurance is involved, we are contractually obligated to collect co-payments, co-insurances, and deductibles, as outlined by your insurance plan. Our office collects patient’s portions at the time of service or to reserve a treatment appointment. Insurance is a benefit to help defray the cost of your treatment and is a contract between you, your employer and the insurance company. As a courtesy, we will bill your insurance for any services rendered, as you provide us with the necessary information. The treatment we recommend will always be based on your individual needs not your insurance coverage. Please understand that your insurance company does not cover all essential services. Your insurance carrier may deny services that are not a benefit or deny services as unnecessary; the services rendered will be your responsibility.
Financial Policy:
Initial
We accept local checks with a picture ID, Visa, Mastercard, American Express, Discover and cash. There is a $35.00 charge for all returned checks. Regardless of insurance coverage the patient/responsible party is ultimately responsible for all services rendered. If the insurance payment has not been received within 60 days of the date of service, any balance remaining is due and must be paid in full and may be increased by minimum rebilling fee of $5 or a monthly interest charge of 2.2% (26.4%APR).
I understand an estimated portion is due at the time of service, however if my account has a remaining balance/credit after the insurance processes my claim I authorize Red Rock Dental / Summerlin Vision to charge/credit the difference to my credit card. Any amounts over $25.00 I will be notified prior to charging my card on file being charged.
Informed Consent for Dental Treatment
Exam & X-rays:
Initial
Your initial visit will consist of a comprehensive oral evaluation and a full set of x-rays (FMX). Full set of x-rays (FMX) are necessary in the diagnosis and treatment of patients at minimum every 5 years. Routine x-rays 2-4 bitewings and / or periapical films are necessary in the diagnosis and treatment of patients at least once per year. Refusal to allow all necessary x-rays to be taken may result in the doctor refusing to diagnose or perform treatment until the needed x-rays are obtained. I do herby to give my consent for the necessary x-rays to be taken.
Dental Scaling/Prophylaxis:
Initial
Thorough cleaning of teeth to allow for optimal health of gingival/gum tissue. It involves removal of soft plaque and harder calculus deposits above and below the gum line. Benefits: Healthy gum tissue, reduction/elimination of bleeding and odors, and reducing the risk of gingivitis/periodontal disease. Alternatives to treatment: Referral for periodontal (gum) evaluation and treatment by a specialist. Risks: bleeding, soreness, swelling, infection of soft tissue, hot and cold sensitivity, stiff /sore jaw joint, mobility with periodontally involved teeth. Consequences of not performing treatment: Gum inflammation and/or infection (gingivitis), tooth decay, deterioration of gum and bone tissue which could lead to tooth loss (periodontal disease).
Anesthetic:
Initial
Injection of anesthetic to the oral tissues to anesthetize the operative site. Benefits: Temporary numbness of tissue and muscle surrounding area of treatment to eliminate pain sensation and allow for proper treatment. Alternatives to treatment: Treatment performed without anesthetic may result in sensitivity and pain. Risks: Allergic reaction, irritation to nerve tissue, stiff or sore jaw joint, swelling of tissue, bruising, and temporary or permanent nerve paresthesia (numbness).
Fillings:
Initial
The removal of dental caries (tooth decay) and replacement with composite resin filling material to regain proper tooth anatomy for function and esthetics. Benefits: Restore tooth structure for proper form and function and prevent more extensive treatment needs. Alternatives to treatment: temporary filling, indirect inlay, onlay, crown, extraction. Risks: Allergy to filling material, tooth sensitivity, filling dislodgement or fracture.
Consequences of not performing treatment: spread of decay leading to more extensive treatment such as onlay, crown, root canal or tooth loss.
Upgraded Material Explanation Form & Guarantee:
Initial
At times, Dr. McCaffrey may recommend materials, which are above and beyond what is covered or considered standard by your Dental Insurance Company, and/or included as a standard per the current Dental Terminology Edition, as represented by the American Dental Association.
Metal Free Restorations: As always Dr. McCaffrey’s number one concern is to treat you with the most advanced materials, techniques and services available to improve the cosmetic and clinical outcome of a healthy mouth. Where possibly Dr. McCaffrey avoids the use of most metals such as mercury fillings, base metals under crowns, and other potentially hazardous materials. Because Dr. McCaffrey has your best interest in mind some of the procedures we provide are above and beyond what your Insurance Company, considers standard.
Dental work with a Guarantee: Expect a higher standard of care when you see Dr. McCaffrey.
Our part:
We will replace any Ceramic restoration (such as crowns, veneers, onlays or inlays) we have placed, which develop a structural problem, at no charge for 5 years. We will replace any basic restoration (such fillings or sealants) we have placed, which develop a structural problem, at no charge for 2 years.
Your Part: the following conditions are required:
You must come in and have a checkup with x-rays, cleaning and fluoride every 6 months (unless instructed to come more frequently). In cases where the dentist detects a history of clenching and/or grinding, the use of an occlusal guard will need to be worn at night.
Acceptance Statement
“I understand Dr. McCaffrey has my best interest in mind and at this time I am accepting upgraded material(s) at Dr. McCaffrey’s recommendation to better treat my conditions present, or because of personal preference. I do understand my acceptance to upgrade the material(s) used, above and beyond what is covered or considered by my Dental Insurance Company or as described in the current dental terminology edition presented by the American Dental Association, can generate additional expenses over the contracted dental network fees.I acknowledge that I have read and understand all the information provided to me regarding Financial Insurance Upgrade and Work Guarantee and that I have received a copy of this form.”
Signature:

Clear
Date:

Month Day Year
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
As our patient we want you to know we respect the privacy of your Personal Health Information (PHI) and will do all we can to secure and protect it. It is our policy to properly determine appropriate uses of PHI in accordance with the government rules, laws, and regulation. When it is appropriate and necessary, we provide the minimum necessary information only to those we feel are in need of it regarding treatment, payment, or health care operations, in order to provide health care in your best interests. Under the law, they are not required to obtain patient consent to use this information.

You may refuse to consent to the use or disclosure of your personal health information, but this must be provided to us in writing. Under the HIPAA laws, we have the right to refuse to treat you should you choose to refuse to disclose your PHI.

By signing below you acknowledge that you have read and understand the notice of privacy practices and all policies escribed above.
Patient or Guarantor Signature:

Clear
Date:

Month Day Year
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
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Patient Information

Insurance Information

Authorization

Dental History

Health History

Medications and Allergies

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

For Office Use Only