IF PATIENT IS A MINOR, PROVIDE THE FOLLOWING
EMERGENCY CONTACT INFORMATION
THE BIGGEST COMPLIMENT OUR PATIENTS CAN GIVE US IS THE REFERRAL OF FAMILY & FRIENDS
IF YOU HAVE DENTTAL INSURANCE, PLEASE PROVIDE THE FOLLOWING & YOUR INSURANCE CARD
ACKNOWLEDGEMENT & CONSENT
Acknowledgement of Insurance Payment Authorization: I hereby authorize and direct payment of the dental insurance benefits otherwise payable to me for services rendered, directly to Plano Top Dental. In the event that the insurance company misdirects payment to me, I understand that I am responsible to immediately remit such payments to Plano Top Dental.
Acknowledgement of Financial Responsibility: 1 agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that either a 1-42% late charge (18% APR) or a $15 late charge per late payment may be added to my account. I further agree to inform Access Dental/Blue Hills Dental of any address or phone number change within 30 days of such a change. In the event I fail to do so I authorize Plano Top Dental to use all due means, including the use of credit history records, to ascertain my new address for billing purposes.
Notice of Privacy Practices: I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.
Acknowledgment of Dental Materials Fact Sheet: I acknowledge that I have received and read the Dental Materials Fact Sheet prior to starting restorative dental work at Plano Top Dental.
Welcome! So that we may provide you with the best possible care, please complete both sides of this dental & medical history form. All information is completely confidential and subject to all applicable laws.
IF YOU ANSWER YES TO EITHER OF THE QUESTIONS ABOVE, PLEASE STOP AND RETURN THIS FORM TO THE RECEPTIONIST.
The following questions are for your benefit and assure that any dental treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition, but they are all associated with proper oral health care. Please answer each question.
I have answered all questions to the best of my knowledge. Should further information be needed, I grant permission to ask my respective healthcare providers or agencies, who may release information to you. I will notify the dentist of any changes in my health or medication.