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  • Patient Information

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  • Insurance Information

  • Medical Insurance:

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  • Dental Insurance:

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  • 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 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.

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  • Dental History

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  • Health History

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  • Medications and Allergies


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  • Short Notice Cancellation/Missed appointment Policy:

  • 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:

  • 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:

  • 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:

  • 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:

  • 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:

  • 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:

  • 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:

  • 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.”

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  • 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.

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  • For Office Use Only


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