New Patient Packet

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Welcome!

Thank you for choosing our office. We strive to provide you with the most gentle, quality care possible.
If you have any questions, or if we can help you in any way, please feel free to ask.

Patient Information (Confidential):

Last Name:*

First Name:*

Initial:

If child, parent / guardian name:

Birth Date:*

Sex:*

Age:*

Social Security Number:

Home Address:*

City:*

State:*

Zip:*

Home Phone:

Work Phone:

Cell Phone:

Email*

Driver's License Number:

How did you hear about our practice?

Spouse's Employer:

Occupation:

How long there?

May we call?

Employer Address:

City:

State:

Zip:

Spouse's Name (Or other parent / guardian):

Social Security Number:

Employer:

Occupation:

How long there?

May we call?

Spouse's Employer Address:

City:

State:

Zip:

If patient is a student:

Name of school / college:

City

State

Full or part time?

Primary Insurance:

Name of Insured:

Birth Date:

Relationship to Patient:

Address:

Dental Insurance Co:

Phone:

Social Security #:

Subscriber ID#:

Group, Contract, Local, or union #:

Address (if different from patient):

Additional Insurance:

Name of Insured:

Birth Date:

Relationship to Patient:

Dental Insurance Co:

Phone:

Social Security #:

Subscriber ID#:

Group, Contract, Local, or union #:

Co-Payments:

If you would like us to keep your payment information on file, please provide credit card information:

SELECT ONE:

Visa

MasterCard

Discover

Amex

Account #:

Expiration Date:

Name on the Card:

Card Type:

Credit Card

Debit Card

ATM

In Case of Emergency:

Name of Primary Care Physician:

City of Primary Care Physician:

Someone we may contact, not living with you:

Phone #’s (home, work, cell):

Authorization:

I authorize my insurance company to make payments directly to the dental office for benefits otherwise payable to me. I authorize release of my records to third party payers, other healthcare professionals or operations, or other entities as deemed necessary by this office. I authorize use of this signature for all insurance submissions. I understand that I am responsible for all charges whether or not they are covered by insurance, as well as any additional collection costs if this office determines they are necessary. I authorize this office to charge my credit card or bank account for any unpaid balances, including those after insurance payment. I understand that in certain circumstances, my credit report may be requested. I have reviewed the information on this form, and it is accurate to the best of my knowledge. I understand that check payments may be converted to automatic bank drafts. I have received a copy of this office’s Notice of Privacy Practices.

Signature:*

Date:*

Our Financial Policy

Patient Name:*

Parent / Guardian Name:

Thank you for choosing us as your health care provider. We strive to provide you with the best quality, gentle dental care possible. If we can help you in any way, please don’t hesitate to ask us.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE WE ACCEPT CASH, CHECKS, OR VISA / MASTERCARD / AMERICAN EXPRESS

Regarding Insurance:

Your insurance is a contract between you and the insurance company. We are not a party to that contract. Dental insurance is not meant to be a pay-all option but meant to be an aid. So please, be aware that some and perhaps all of the services provided under your particular policy may be considered “Non-Covered Benefits” above their “Usual and Customary Fee” or based on a set “Fee Schedule”. Your benefits are dependent on how much your employer paid for your particular plan. If you have any questions regarding the detail of your plan, we ask that you contact your job. Regardless of what insurance pays, the final balance on your account is considered your responsibility. We are happy to assist you in receiving your maximum allowable benefits and require all pertinent insurance information to be given to us so that eligibility and general benefits can be verified. Once confirmed, our office will be able to accept assignment of benefits and bill your insurance company directly. Please understand that we cannot predict exactly what your insurance company will pay on a particular procedure or service, and only an estimate can be determined of the charges based on the information your insurance company is willing to provide. An annual deductible and any required co-payment on a particular service will have to be collected at the time of service, and can only be based on the general information released by your insurance company. We will bill your insurance company as services are rendered. Payment is expected within 30 days of that billing. Any services not paid after the 45-day wait period will become immediately due in full. Accounts over 60 days past due will be subject to a monthly billing service charge. Accounts over 90 days will be sent to collections.

Usual and Customary Rates:

Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment, regardless of any insurance company’s arbitrary determination of usual and customary rates. Dental insurance usually covers Basic dental procedures. Complex comprehensive procedures and Cosmetics are often times “Non-Covered Services”.

Change or Termination of Insurance:

If your insurance coverage changes or is terminated, please notify our office, so we can update our information. If we do not receive advance notification, you could be liable for any charges the insurance did not cover.

Returned Checks, Service Charge on Unpaid Balance:

We will be happy to accept your payment by check. For all returned checks, there will be a maximum service charge of $50. We also reserve the right to charge your account a monthly billing service charge on unpaid balances after 60 days.

Cancellation of Appointment:

If for any reason you are unable to keep your appointment, kindly give us 2 business days’ notice (48 business hours). If you have more than one broken appointment within the last year, your account will be charged a fee of $60. If you have an emergency, we truly understand, and will not charge a fee to your account.

I have had the opportunity to read this form, ask questions, understand and agree to the terms of the Financial Policy.

Print Name:*

Signature:*

Date:*

Dental Treatment Consent Form

Please read and initial the items checked below.

Patient Name:*

WORK TO BE DONE

I understand that I am having the following work done:*

Fillings

Bridges

Crowns

Extractions

Impacted teeth removed

General Anesthesia

Root Canals

Other

Initial:*

DRUGS AND MEDICATIONS

I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

Initial:*

CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of condition found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give permission to the dentist to make any/all changed and additions as necessary.

Initial:*

REMOVAL OF TEETH

Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery etc.) and I authorize the dentist to remove the recommended teeth and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, and some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days of months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

Initial:*

CROWN, BRIDGES AND CAPS

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily, and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size and color) will be before cementation.

Initial:*

DENTURES, COMPLETE OR PARTIAL

I realize that full or partial dentures are artificial, constructed of acrylic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, include looseness, soreness and possible breakage. I realize the final opportunity to make changed in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost of the procedure is not included in the initial denture fee.

Initial:*

ENDODONTIC TREATMENT (ROOT CANAL)

I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment, I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).

Initial:*

PERIODONTAL LOSS (TISSUE & BONE)

I understand that I have a serious condition, causing gum and bone infection or loss, and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.

Initial:*

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I am signing below that I have read and understood this form.

Signature of Patient / Parent / Guardian:*

Date:*

Patient Signature Page

I. Notice of Privacy Practices

By signing below, I acknowledge that I have read Classic Smiles Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Signature:*

Date:*

II. Payment, Insurance, and Financial Arrangement Policies

By signing below, I agree to the terms of the Classic Smiles Patient Acknowledgements, Agreements, and Authorizations document.

Signature:*

Date:*

III. Appointment Agreement

In order for us to respect the time of all of our patients, we ask that you help us in regards to the appointments that have been especially reserved for you! Please be on time for your appointments. Your appointment time is reserved specifically for you. Arrivals of 10 minutes or more past your reserved time will be re-evaluated for what can be done that day.

Signature:*

Date:*

IV. Release of Information to Insurers and Assignment of Benefits

I consent to Classic Smiles’ use and disclosure of my Protected Health Information to carry out payment activities in connection with insurance claims. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I further authorize and direct payment to Classic Smiles.

Signature:*

Date:*

(If patient is a minor or disabled the Parent, Guardian, or Attorney-in-Fact must sign and complete the Responsible Party section below)

Responsible Party (If patient is under 18 or disabled)

First:

Middle:

Last:

Jr / Sr:

Street:

City:

State:

Zip:

Home Phone:

Work Phone:

Patient SSN:

Patient Date of Birth:

Sex:

49239

Welcome!

Patient Information (Confidential):

If patient is a student:

Primary Insurance:

Additional Insurance:

Co-Payments:

In Case of Emergency:

Authorization:

Dental History

Please select all that apply:

Medical History

Please select all that apply:

OFFICE USE ONLY

Our Financial Policy

FULL PAYMENT IS DUE AT THE TIME OF SERVICE WE ACCEPT CASH, CHECKS, OR VISA / MASTERCARD / AMERICAN EXPRESS

Regarding Insurance:

Usual and Customary Rates:

Change or Termination of Insurance:

Returned Checks, Service Charge on Unpaid Balance:

Cancellation of Appointment:

Dental Treatment Consent Form

WORK TO BE DONE

DRUGS AND MEDICATIONS

CHANGES IN TREATMENT PLAN

REMOVAL OF TEETH

CROWN, BRIDGES AND CAPS

DENTURES, COMPLETE OR PARTIAL

ENDODONTIC TREATMENT (ROOT CANAL)

PERIODONTAL LOSS (TISSUE & BONE)

Patient Signature Page

I. Notice of Privacy Practices

II. Payment, Insurance, and Financial Arrangement Policies

III. Appointment Agreement

IV. Release of Information to Insurers and Assignment of Benefits

Responsible Party (If patient is under 18 or disabled)

Website and Social Media Release Form

Smile Survey