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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Do you have, or have you had, any of the following?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
With the recent advancements in materials and techniques, many of our patients are asking more questions about cosmetic dental procedures. In order to better serve you, please take a moment and let us know how you feel about the appearance of your smile.
Thank you for selecting us as your dental care provider. We are committed to the highest level of quality, preventive treatment. Outlined below is our financial policy. Please read it carefully and sign it before being seen by the doctor.
Our practice is committed to providing the best treatment for our patients, based on a diagnosis of what is needed to save and prevent further loss or damage to your gums or teeth. We charge fees that are usual and customary for our area. Our diagnosis will not be based on what your insurance company will cover, the amount of money you have left towards your maximum, or how economical the treatment will be. Again, it will be based on what is in the best interest of your dental and health care. Regardless of any insurance company’s arbitrary determination of what is usual and customary, you are responsible for payment.
Be aware that this is only an estimate. The actual amount could vary depending on what your insurance will cover or unexpected changes of treatment. You are ultimately responsible for any balance for services rendered. We cannot bill your insurance company unless you give us your insurance information. This information must be provided before treatment begins. Your insurance policy is a contract between your employer and your insurance begins. Your insurance policy is a contract between your employer and your insurance company. We are not a party to that agreement. Until your insurance company has paid their portion of services rendered, the unpaid balance will show on your monthly statement.
I have read, understand and agree to the above terms.
*If submitting via email, a signature will be obtained at the time of your appointment. Thank You!