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English (US)
Atlanta Place Dentistry
YOURTULSADENTIST.COM
How Can We Help You?
New Patient with an appointment
New Patient without an appointment
Update Medical History
How did you hear about us?
Ex: Current Patient / Google Search / Facebook / Insurance Referral
Your Interests:
Routine Cleaning & Checkup
Emergency Appointment
General Questions
Botox or In-Office Whitening
Invisalign
Other
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BEFORE YOU BEGIN
Do NOT refresh your browser during this process. Refreshing will erase your progress and you will have to begin again.
WHAT WILL YOU NEED IN THIS PROCESS?
You will be asked to provide 1) a photo of your insurance cards and 2) a valid form of identification in this process. Once you have those ready, click next.
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Is there anything bothering you or any particular concern you have?
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General Information
Patient Name
First Name
Last Name
Preferred Name
Johnathon or "Johnny"
Is this patient under the age of 18?
Yes
No
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Mobile Phone
We will use this number to text your appointment reminders.
Home Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
You may wait to share this at your appointment.
CLICK HERE TO ADD ADDITIONAL FAMILY MEMBERS TO YOUR FILE
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Billing Information
Person Responsible for the Account:
First Name
Last Name
Responsible Party Date of Birth:
-
Month
-
Day
Year
Responsible Party Phone:
Financial Policies:
If payment for the entire new balance within 25 days of the monthly billing date, or settlement of pending insurance claims, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1.5% per month (or a minimum charge of $3.00 for a balance under $200.00) which is an annual percentage rate of 18% applied to the last month’s balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.
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Do you have Dental Insurance?
Yes
No
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Insurance Information
Dental Insurance Company:
Subscriber Name:
Could be different from the patient.
Subscriber Date of Birth:
-
Month
-
Day
Year
Subscriber ID:
Insurance Card Front:
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Insurance Card Back:
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Place of Employment:
Company's Benefits Administrator:
PERMISSION TO SUBMIT INSURANCE CLAIMS:
By providing the information above, I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals.
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We Love Non-Insurance Patients
OUR MEMBERSHIP COULD BE PERFECT FOR YOU!
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Medical History
Patient Name:
*
First Name
Last Name
What is your estimate of your general health?
*
Excellent
Good
Fair
Poor
Most Recent physical examination:
*
Name of Physician and Their Specialty
*
DO YOU HAVE or HAVE YOU EVER HAD an allergic reaction to
*
None
Aspirin, Ibuprofen, Acetaminophen
Penicillin
Erythromycin
Tetracycline
Codeine
Local Anesthetic
Floride
Metals (gold, stainless steel)
Latex
Other
Please list any other allergies you may have:
*
CLICK HERE IF YOU WILL NEED PRE MEDICATION BEFORE YOUR APPOINTMENT
If you are in need of premedication for your first visit, please contact your primary care physician to fulfill this request. Once you are a patient of record, we will be able to fulfill this request in the future.
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Medical History, Part 2
Any reason for previous hospitalization for illness or injury?
*
DO YOU HAVE or HAVE YOU EVER HAD
*
Heart Problems
Heart Murmur
Rheumatic Fever
Scarlet Fever
High Blood Pressure
Low Blood Pressure
Hypoglycemia
A Stroke
Artificial Prosthesis (ie, heart valve or joints
Anemia, or other blood disorder
Prolonged bleeding due to a light cut
Emphysema
Tuberculosis
Asthma
Breathing or sleep problems
Sleep Apnea
Kidney disease
Liver disease
Jaundice
Thyroid or Parathyroid Disease
Hormone Deficiency
High Cholesterol
Diabetes
Stomach or Duodenal Ulcer
Digestive Disorders (ie, Gastric Reflux)
Osteoporosis/osteopenia (ie, taking bisphosphonates)
Arthritis
Glaucoma
Contact Lenses / Glasses
Head or Neck Injuries
Epilepsy, Convulsions, Seizures
Neurologic Problems
Viral Infections and Cold Sores
Any Lumps or Swelling in the Mouth
Hives, Skin Rash, Hay Fever
Venereal Disease
HIV / AIDS
Hepatitis
Tumor, Abnormal Growth
Radiation Therapy
Chemotherapy
Emotional Problems
Psychiatric Treatment
Antidepressant Medication
Alcohol / Drug Dependency
None
Please check if you are:
*
presently being treated for any illness
aware of changes in your general health
taking medication for weight management (ie, fen-phen)
taking dietary supplements
often exhausted or fatigued
subject to frequent headaches
a smoker
a former smoker
considered a touchy person
often unhappy or depressed
FEMALE - taking birth control pills
FEMALE - pregnant
MALE - prostate disorders
None
Please list all medications, supplements, and or vitamins taken within the last two years and WHY.
*
Your Preferred Pharmacy & Where
*
Example: CVS at 71st and Yale
Please describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment:
*
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Signature
*
Clear
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REQUEST OF DENTAL RECORDS
(Optional) Click Here to Begin the Dental Record Transfer Process
Please Contact Your Previous Dentist:
Most clinics require you to make the initial request to transfer your dental records. Please contact your previous clinic and request x-rays and previous clinical notes to be sent to info@yourtulsadentist.com.
Dear Insurance Patients:
Please be aware that your dental insurance will MOST LIKELY NOT INFORM a new clinic of your dental insurance frequencies and duplicate services may not be covered. Please contact your insurance company to ensure duplicate services will be covered.
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Terms and Policies, Page 1 of 3
FINANCIAL AND APPOINTMENT POLICY
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Terms and Policies, Page 2 of 3
NOTICE OF PRIVACY PRACTICES
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Terms and Policies, Page 3 of 3
INFORMED CONSENT
I HAVE READ AND ACCEPT ALL TERMS AND POLICIES.
*
Clear
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Photo of the Responsible Party's ID
*
Click Here to Take A Photo
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