Prince George - DENTAL REGISTRATION AND HISTORY

DENTAL REGISTRATION AND HISTORY
PATIENT INFORMATION
Today's Date

Month Day Year
Date Date Picker Icon
Patient Name *

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birthdate *

Month Day Year
Date Date Picker Icon
Age
Sex:

Male Female
Status

Single Married Widowed Separated Divorced
Patient SS#
Occupation
Employer

Employer Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer Phone
Spouse's Name

First Name Last Name
Birthdate

Month Day Year
Date Date Picker Icon
Spouse's Phone Number
SS#
Whom may we thank for referring you?

Guarantor Information
Name Of Account Guarantor (If you are over 18 you are your own guarantor) *
Guarantor SS# *
Relationship to Patient *
Dental Insurance Information
Insurance Subscriber's Name

First Name Last Name
Birthdate

Month Day Year
Date Date Picker Icon
Relationship To Patient
SS#
Insurance Co.
Insurance Co. Phone Number
Insurance Identification Number
Group#
Does The Patient Have A Secondary Insurance

Yes No
Subscriber Name

First Name Last Name
Subscriber DOB

Month Day Year
Date Date Picker Icon
Insurance Co.
Insurance Co Phone #
Insurance Identification #
Group#
ASSIGNMENT AND RELEASE

1, the undersigned certify thal I (or my dependenl) have insurance coverage with
sign directly to Dr.
all insurance benefits, ii any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature *
Relationship *
Date

Month Day Year
Date Date Picker Icon

PHONE NUMBERS
Home *
Cell
Work
Ext
Spouse's Cell
Best time and place to reach you
Emergency Contact: (Specify an adult we should contact in the event of an emergency)
Name *

First Name Last Name
Relationship *
Home Phone *
Cell
Work Phone

Patient Consent & Notice Of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ) , I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- --Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
- --Obtain payment from third party payers
- --onduct normal healthcare operations such as quality assessments and physician certifications
- I have been informed by you of your Notice of Privacy Practices describing the uses and disclosures of my health information. I have been given the right to review such Notice Of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice Of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of Notice Of Privacy Practices.

-I Understand that I may request in writing that you restrict how my private information is used and/or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

-I understand that l may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

-I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.
- Description of specific information to be used and/or disclosed: Insurance Company Name. Subscriber ID and information. treatment and treatment plan. medical history and x-rays.
- Person or entit y requesting and receiving the information and authorized to make the requested use of disclosure: Insurance, Laboratory, Specialist and any additional authorized persons listed below.
Additional Authorized Persons & Relationship:
This authorization shall remain in effect for 12 months from the date signed. I understand I may refuse to sign this authorization with the understanding that you may refuse to perform treatment.
Patient Name

First Name Last Name
Date

Month Day Year
Date Date Picker Icon
Guarantor Signature *
Relationship To Patient *
OFFICE USE ONLY
We attempted to· obtain consent in acknowledgement of this Notice Or Privacy Practices, but unable to do so for reasons documented below.
Name

First Name Last Name
Initials

Prince George Dental

10545 South Crater Rd. Petersburg, VA 23805
804-732-8557

Patient Responsibility Agreement

Patient Responsiblllty - Payment Is Due At Time Of Service

We have several payment options available

Cash	5% discount for treatment paid in full prior to the time of treatment ONLY For patients without dental insurance
Credit	All major credit cards are accepted
Check	We gladly accept your check; if your check Is dishonored or returned for any reason we will electronically debit your account for the amount of the check plus a processing fee of 45.OO.
Care Credit	Please see brochure for details
PGSPP	Prince George Smile ProtectionPlan, our in-house dental discount plan, please ask for details

Appointment Policy

If you are late to your appointment we reserve the right to reschedule your appointment if necessary.
It is your responsibility to remember your appointment, as a courtesy reminder calls, emails, and text messages are sent.
If you must reschedule or cancel your appointment a 48 hour notice is required, messages are not an acceptable way to cancel an appointment. If you do not come to your scheduled appointment or cancel your appointment with less than 48 hours notice you may be charged a cancellation fee of $50.00 or 10% of the scheduled treatment.

Patient Visitors Policy
- Patients that have an appointment are allowed one guest during the visit; the guest may remain in the waiting room while the patient is being treated in the clinical area.
- We require that no children under the age of 12 remain in the waiting room unattended.
- Unless child is being treated by the doctor please do not bring them in the clinical area.
Composite Fillings
- As a reminder, this office is amalgam free (silver filling). We only place composite fillings (white/tooth colored). Some insurance companies downgrade composite fillings and pay at a lesser rate. Therefore, the patient is responsible for the difference in payment. If you have any questions please ask the front desk and they will be happy to help.
Private Dental Insurance
- As a courtesy to our patients we will file your claims for dental services we provide to you. We require the patient responsibility and deductible to be paid at the time of treatment. You are responsible for providing accurate, current insurance information at each visit. Please present your insurance card at each visit. You are responsible for any remaining balance after your insurance company has processed your claim. If your insurance company does not process and pay your claim for any reason after 60 days you will be responsible for the balance.
In consideration for services rendered to me or my dependent child, I authorized Dr. Shahareyar Sayyar and associates to bill my insurance carrier for all services provided and that all payment for services rendered will come directly to Shahreyar S. Sayyar. I give authorization to the release of any information requested by my insurance company with respect to insurance claims. I assume all responsibility for any portion of treatment cost not paid by my insurance company. I agree that if I do not have insurance or my insurance Is not active at the time of treatment, I AM RESPONSIBLE FOR PAYING IN FULL AT THE TIME OF SERVICE FOR ALL TREATMENT. If for any reason my account becomes delinquent, I agree to pay an interest rate of 1.5% p er month, or 18% annually, on balance more than 60 days old, plus any attorney's fees that may be added.

I have read and understand the Financial, Insurance , and Patient responsibilities as noted in this authorization
Patient Name

First Name Last Name
Guarantor Signature: *
Relationship: *
Date

Month Day Year
Date Date Picker Icon
Should be Empty:

	Yes	No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Gums swollen or tender
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth

	Yes	No
AIDS
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally, with extractions or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Do you wear contact lenses?
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis
Herpes
High Blood Pressure
HIV Positive
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swelling of Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal Disease
Weight Loss, unexplained

DENTAL REGISTRATION AND HISTORY

Dental Insurance Information