New Patient Paperwork

PATIENT ENROLLMENT

Last Name:

First:

Middle Initial:

How do you wish to be addressed?

Date of Birth:

Status:

Single Married Divorce

Gender:

Male Female

Full time Student?

Yes No

School:

Address:

City:

State:

ZIP:

Telephone (Home):

(Work):

(Mobile):

Email:

Employer:

Occupation:

Soc. Sec. No.:

Is patient covered by another dental insurance?

Yes No

Insurance Co.:

How did you hear about our practice? Whom may we thank for your referral?

SPOUSE, PARENT OR RESPONSIBLE PARTY

Last Name:

First:

Middle Initial:

Telephone:

Employer:

Dental Insurance Co.:

Member ID:

Group #:

EMERGENCY CONTACT

Last Name:

First:

Middle Initial:

Address:

Telephone:

INDIVIDUALS TO WHOM MEDICAL AND ACCOUNT INFORMATION MAY BE RELEASED

Add New

AUTHORIZATION

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize the release of any information concerning my (or my child’s) health care, advice and treatment to another dentist.

I hereby authorize payment of insurance benefits directly to Dr. April Stone, otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid, in whole or in part by my dental care payer.

I attest to the accuracy of the information on this page.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Relationship to Patient:

DENTAL & MEDICAL HEALTH HISTORY

Patient Last Name:

Patient First Name:

DENTAL HISTORY

Reason for today’s visit:

Date of last dental visit:

Former dentist:

Date of last dental x-rays:

Please check if you have/had:

Bad breath:

Yes No

Blisters on lips or mouth:

Yes No

Burning sensation on tongue:

Yes No

Chew on one side of mouth:

Yes No

Cigarette, pipe, or cigar smoking:

Yes No

Dry mouth:

Yes No

Smokeless tobacco:

Yes No

Food collection between teeth:

Yes No

Clench or grind teeth:

Yes No

Growths or sore spots in your mouth:

Yes No

Gums swollen, tender or bleeding:

Yes No

Head, neck, jaw pain, or aches:

Yes No

Lip or cheek biting:

Yes No

Loose teeth or broken fillings:

Yes No

Mouth breathing:

Yes No

Orthodontic treatment:

Yes No

Nitrous Oxide:

Yes No

Periodontal treatment:

Yes No

Sensitivity to pressure or irritants (cold, heat, sweets):

Yes No

How often do you floss?

How often do you brush?

Have you ever had an allergic reaction to Novocaine, local, or general anesthetics?

Yes No

Have you ever had trouble from previous dental care?

Yes No

If Yes, please explain

MEDICAL HISTORY

Physician’s Name:

Date of last visit:

Physician’s Address:

Blood Pressure

Have you had any serious illnesses or operations?

Yes No

(Women) Are you pregnant?

Yes No

If yes, please describe

Due date:

Nursing?

Yes No

Taking birth control pills?

Yes No

Please check if you have/had:

Allergies, hay fever, sinusitis:

Yes No

Anemia:

Yes No

Arthritis, Rheumatism:

Yes No

Artificial heart valves:

Yes No

Artificial joints:

Yes No

Bleeding abnormally with operations or surgery:

Yes No

Blood disease, Clotting disorders:

Yes No

Cancer:

Yes No

Chemical Dependency:

Yes No

Chemotherapy:

Yes No

Circulatory Problems:

Yes No

Cortisone Treatments:

Yes No

Cough, persistent or bloody:

Yes No

Diabetes:

Yes No

Emphysema:

Yes No

Epilepsy:

Yes No

Fainting:

Yes No

Glaucoma:

Yes No

Headaches:

Yes No

Heart murmur:

Yes No

Heart problems:

Yes No

Herpes:

Yes No

High blood pressure:

Yes No

Any immune deficiency:

Yes No

Jaundice:

Yes No

Kidney disease:

Yes No

Low blood pressure:

Yes No

Mitral valve prolapse:

Yes No

Pacemaker:

Yes No

Radiation treatments:

Yes No

Respiratory disease:

Yes No

Rheumatic fever:

Yes No

Scarlet fever:

Yes No

Shortness of breath:

Yes No

Sinus trouble:

Yes No

Sickle cell anemia:

Yes No

Skin rash:

Yes No

Slow healing wounds:

Yes No

Stroke:

Yes No

Thyroid problems:

Yes No

Tonsilitis:

Yes No

Venereal disease:

Yes No

Tuberculosis:

Yes No

Tumor or growth on head/neck:

Yes No

Ulcer:

Yes No

Do you consume alcoholic beverages?

Yes No

Are you currently under the care of a Physician?

Yes No

Are you allergic/sensitive to Latex?

Yes No

Allergic to Penicillin, Aspirin, or other drugs?

Yes No

Asthma

Yes No

Hepatitis type

If Yes, please specify:

List any medications that you are taking:

AUTHORIZATION AND RELEASE

I have read and answered the above questions to the best of my knowledge.

Patient/Guardian Signature:

Date:

HIPAA CONSENT FORM

SECTION A: PATIENT CONSENT TO RECEIVE MAIL, E-MAIL, AND/OR TELEPHONE MESSAGES

Patient Name:

Do we have your permission to:

Mail a recall or appointment reminder to your home?

Yes No

Leave appointment reminders on your answering machine/voicemail, email, or text

Yes No

Leave billing or dental information via answering machine/voicemail, email, or text

Yes No

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Officer: Debra Poppell

Telephone: (904) 284-6688

Fax: (904) 212-2333

Address: 91 Branscomb Road, Unit 7, Green Cove Springs, FL 32043

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

SECTION C: SIGNATURE

have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

Signature:

Date:

If this Consent is signed by a personal representative (parent/guardian) on behalf of the patient, complete the following:

Personal Representative’s Name:

Relationship to Patient:

SECTION D: FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (please specify)

Please Specify:

Signature:

Date:

FINANCIAL POLICY

Patient Name:

Date:

Thank you for choosing Asbury Family Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

PAYMENT OPTIONS

Full payment is due at time of service. We accept:

Cash, Visa, MasterCard, American Express or Discover Card. WE DO NOT ACCEPT CHECKS.
Convenient Monthly Payment Options Subject to credit approval from CareCredit Healthcare Credit Card, which allows you to pay over time.

INSURANCE

Asbury Family Dentistry provides insurance company billing as a courtesy to our patients. The patient portion of particular dental service(s) is estimated and due at the time of service. This amount may be subject to adjustment when the dental service(s) claim(s) are adjudicated by the insurance company. In addition, certain insurance companies have annual limitation for the amount of dental services that can be reimbursed within each plan year. If you or your family exceed these annual limitations in any plan year, you will be responsible for the full amount of dental services that exceed the particular plan’s limitations. The patient is responsible for monitoring the amount of his/her remaining benefits for any annual benefit period. The patient may not rely upon any information provided by Asbury Family Dentistry staff regarding his/her remaining benefit in any such benefit period.

The claims we submit to insurance companies indicate that you have assigned those benefits to Asbury Family Dentistry. However, if you are paid by the insurance company instead of Asbury Family Dentistry, you then become responsible for the total account balance and payment would be expected immediately.

If you or your family has more than one dental insurance program, we will assist you in obtaining the maximum benefits available.

You as a patient are always responsible for any charges that are not covered by your insurance.

IMPORTANT

We require a 24-hour confirmation for all appointments. On any appointment 90 minutes or longer we require 48 hours' notice if you need to cancel or reschedule. WE REQUIRE ALL APPOINTMENTS TO BE CONFIRMED. If we do not receive a confirmation for your appointment we will consider you are not coming to your appointment and will find that spot. We do have an answering service that is available for you to leave a message if our office is closed or we can not be reached

If you NO SHOW OR CANCEL with less than 24 Hour notice for a cleaning appointment, we will be REQUIRED to pay a $25 deposit to reach out

We REQUIRE a 24-hour notice to cancel or reschedule to avoid losing your deposit. A new deposit will be required to reschedule an appointment.

Our NO SHOW or CANCELATION fee is $50 and must be paid to reschedule an appointment. Please CONFIRM your appointments to potentially avoid losing your reserved time.

There is a 3% surcharge for CREDIT transactions. No charge for DEBIT or CASH. WE DO NOT ACCEPT CHECKS

After 2 missed appointments, you will be REQUIRED to pay your visit in full to reschedule.
After 3 missed appointments, you will be dismissed from the practice.

Responsible Party Signature:

Date:

Your information will be encrypted.

New Patient Paperwork

PATIENT ENROLLMENT

SPOUSE, PARENT OR RESPONSIBLE PARTY

EMERGENCY CONTACT

INDIVIDUALS TO WHOM MEDICAL AND ACCOUNT INFORMATION MAY BE RELEASED

AUTHORIZATION

DENTAL & MEDICAL HEALTH HISTORY

DENTAL HISTORY

MEDICAL HISTORY

AUTHORIZATION AND RELEASE

HIPAA CONSENT FORM

SECTION A: PATIENT CONSENT TO RECEIVE MAIL, E-MAIL, AND/OR TELEPHONE MESSAGES

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

SECTION C: SIGNATURE

SECTION D: **FOR OFFICE USE ONLY**

FINANCIAL POLICY

PAYMENT OPTIONS

INSURANCE

**IMPORTANT**

SECTION D: FOR OFFICE USE ONLY

IMPORTANT