Patient Information

Last Name

First Name

Middle

Preferred Name

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email address

Date of Birth

Social Security #

How were you referred to our office?

Emergency Contact

Name

Phone

ACCOUNT INFORMATION

Person Financially Responsible for Account

Check if same as patient

Name

Relationship to Patient

Birthdate

Social Security Number

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

DENTAL INSURANCE

PRIMARY CARRIER

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SECONDARY CARRIER

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Financial Agreement

We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health. The following is a statement of our Financial Policy, which we require that you read, agree to, and sign prior to any treatment. We are pleased to discuss our professional fees with you at any time. Your clear understanding of the Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility upon arrival at your first appointment.

ADULT PATIENTS

Adult patients are responsible for full payment at time of service.

MINORS ACCOMPANIED BY AN ADULT

The adult accompanying a minor, his/her parents or guardians are responsible for full payment at time of service.

INSURANCE

We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company.

Please understand that we will provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits will determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time. If you are paid by the insurance company instead of our practice, you then become responsible for the total account balance and payment would be expected immediately.

We ask that you sign this form and/or any other necessary documents that may be required by your insurance company.

DEDUCTIBLE/CO-PAYMENT

We may ask that you pay the deductible and co-payment, which is the estimated amount, not covered by your insurance company, by cash, check, credit card or Patient Financing (Care Credit) at the time we provide the service to you.

CONSENT for TREATMENT

I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by a doctor to make a thorough diagnosis.
Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed up on by me and to employ such assistance as required to provide proper care.
I agree to use of anesthetics as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

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 of Patient, Parent or Guardian

Date

Release of Record

I authorize the release of records and x-rays relevant to dental treatment and request that they be sent to Abington Family Dentistry, P.C.

Address: 314 N. State Street, Clarks
Summit, PA 18411
Fax: 570-586-5857

Email: abingtonfamilydentistry@frontier.com

Phone: 570-586-6500

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.

Patient’s Name / Signature

Date of Birth

Today's Date

DENTAL HISTORY

Date of Last Dental Visit

Last Dental Cleaning

Last Full Mouth X-rays

What was done at your last dental visit?

Previous Dentist’s Name

Telephone

Address

City

State

Zip

How often do you have dental exams?

How often do you brush your teeth?

How often do you floss?

What other dental aids do you use? (ie: toothpick, stimudent)

Do you have any dental problems now?

Dental Conditions - Please check all that apply:

Sensitive to

Hot

Cold

Chewing

Sweets

Clench / grind your teeth while awake or asleep

Have you ever had

Orthodontic treatment

Oral surgery

Periodontal treatment

Your teeth ground or the bite adjusted

A bite plate or mouth guard

A serious injury to the mouth or head

Dental Implants

Are you satisfied with your teeth’s appearance?

Would you like to replace your silver fillings?

Would you like to keep all your teeth all of your life?

MEDICAL HISTORY

Physicians Name

Phone #

Have you had any medical care within the past two years?

Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?

Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates?

Have you been a patient in the hospital during the past five years?

Have you ever been told to take an antibiotic pre-medication prior to dental treatment? (Due to joint replacement or cardiac issues?Radio buttons

Yes No

If other, Please specify

Women - Are you:

Pregnant / Trying to get pregnant?

Nursing

Taking oral contraceptives

Have you ever had any serious illness not listed above?

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.

Patient's Name / Signature

Date

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