Patient Dental and Registration and History

PATIENT INFORMATION

Date

SS / HIC / Patient ID No.

Patient Name (First Name)

Last Name

Middle

Address

Email address

City

State

Zip Code

Age

Birthdate

If Partnered, for how many years?

Patient Employer/School

Occupation

Employer/School Address

Employer / School Phone No.

Spouse's Name

Birthdate

SS No.

Spouse's Employer

Who may we thank for referring you?

DENTAL INSURANCE

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group No.

Subscriber's Name

Birth Date

SS #

Relationship to Patient

Insurance Co.

Group No.

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to

Dr.

all insurance benefits, if 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 authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan Is completed or one year from the date signed below.

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.

Name / Signature of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient

PHONE NUMBERS

Home Phone No.

Work Phone No. (Ext)

Cell Phone No.

Spouse's Work No.

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT

(Specify someone who does not live in your household.)

Name

Relationship

Home Phone

Work Phone

DENTAL HISTORY

Reason for today's visit

Former Dentist

City / State

Date of last dental visit

Date of last dental X-rays

Please choose on "yes" or "no" to indicate if you have had any of the following:

If Other, please specify

HEALTH HISTORY

Physician's Name

Date of last visit

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes No

If other, Please specify

Do you wear contact lenses?

Yes No

(Women) Are you pregnant?

Yes No

If yes, due date

Taking birth control pills?

Yes No

Are you nursing?

Yes No

MEDICATIONS

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Phone No.

ALLERGIES

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Local Anesthetic

Penicillin

Sulfa

Other

If other, please specify

UPDATES (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?

Yes No

If yes, For what conditions?

Are you taking any new medications?

Yes No

If so, what?

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.

Patient's Signature

Date

Doctor's Signature

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

have received a copy of this office's Notice of Privacy Practices.

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.

Patient Name / Signature

Date

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 refuse to sign
Communications barriers prohibited obtaining the acknowledgment
An emergency prevented us from obtaining acknowledgment
Other (Please Specify)

@2002 American Dental Association All Rights Reserved

Reproduction and use of this form by dentists and their staff are permitted. Any other use, duplication of this form by any other party requires the written approval of the American Dental Association.

This form is educational only, does not constitute legal advice, and covers only federal, not state, law (Augusta 2014)

APPOINTMENT SCHEDULE ACKNOWLEDGEMENT

Dr. Makerson and her team would like to take the time to thank you for choosing our dental office for your oral health. It is our goal to provide the best care and service to you. Your family and friends. This letter is to inform all our wonderful patients of the updates with our schedule.

Our team arrives at 8:00 a.m., Monday - Thursday to assist you with appointments or any questions. It is our intention to always stay on schedule. Occasionally we may experience interruptions in our schedule due to emergencies or other delays. Please be on time for your appointments. Most procedures require the full amount of scheduled time for treatment. If you are more than 10 minutes late, we may require the appointment to be rescheduled. All our appointments are scheduled specifically for each patient;

THEREFORE. A MISSED APPOINTMENT HURTS YOU, (THE PATIENT), THE TEAM, AND PROSPECTIVE PATIENTS. IT'S VERY IMPORTANT THAT YOU KEEP All SCHEDULED APPOINTMENTS. A $25.00 FEE Will BE CHARGED FOR All MISSED APPOINTMENTS, (NO SHOWS} AND APPOINTMENTS CANCELLED LESS THAN 24 HOURS.

WE KNOW THAT CERTAIN CIRCUMSTANCES ARE BEYOND YOUR CONTROL, SUCH AS EMERGENCIES. AND WORK SCHEDULES, SOMETIMES ARISE, HOWEVER. WE WISH THAT YOU GIVE US A CALL. NO CALL, NO SHOWS, Will BE CHARGED. REPEATED CANCELLATIONS OR MISSED APPOINTMENTS Will RESULT IN LOSS OF FUTURE APPOINTMENT PRIVILEGES.

We welcome new patients and are grateful to our patients who have referred their family and friends to our office. Your expressions of confidence are greatly appreciated. We look forward to serving you in years to come and thank you in advance for your cooperation.

Thank you,
Makerson Dental Team

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

INSURANCE/BILLING POLICY

INSURANCE: Filling insurance is a service we provide as a courtesy for diagnostic and surgical procedures. You are asked to assign benefits to us for services rendered. In the event that the insurance company sends a check to you for services, we ask that you immediately send the check to our business office.

Insurance companies may set fees which are below our customary charges. In this event, the patient is obligated for the full amount billed. PLEASE REMEMBER YOUR DENTAL INSURANCE IS AN AGREEMENT BETWEEN YOU AND THE INSURANCE CARRIER. We are glad to assist you in collection from insurance carriers, however, the ultimate responsibility is yours.

If your insurance company requires an annual deductible, this amount must be paid before any basic and/or major services are rendered. While we estimate your payment at the time services are rendered, the insurance company may or may not pay the remaining portion. In the event your insurance company does not pay its estimated portion, you will be responsible for the balance due.

IF TREATMENT IS NECESSARY, A $200.00 DEPOSIT IS REQUIRED WHEN APPOINTMENT IS SCHEDULED

BILLING: Even though an insurance claim has been filed, you will receive a statement each month indicating your current balance. Often times this will reflect a balance prior to insurance reimbursement. Balances become past due at 90 days and a 1.5% monthly finance charge will be added to your current balance.

Our office offers a no-interest patient payment plan available through CARE CREDIT. (Offer is subject to Credit Approval). Please see the office manager for an application or apply online at: carecredit.com

We accept VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, CASH, and PERSONAL CHECKS. There will be a $35.00 service charge on all returned checks. PLEASE BE ADVISED PAYMENTS ARE DUE AT THE TIME SERVICES ARE RENDERED.

Our purpose is to deliver the best dental care available. We appreciate your time in reading our policies and hope you understand the need for stating these. You are asked to sign below to indicate that our billing policy has been read. If you have any questions, please do not hesitate to direct them to our business office.

I have read and understand the above policies

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.

Patient's Signature

Staff Signature

Date

COVID-19 Pandemic Dental Treatment Consent From

knowingly and willingly consent to have dental treatment completed during the COVID-19 Pandemic.

I understand the COVID-19 virus has a long incubation period during which carries of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

Dental procedure creates water spray. It is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus.

I have been aware of the CDC and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months.

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

Fever
Shortness of Breath
Loss of sense of Taste and Smell
Dry Cough
Runny Nose
Sore Throat

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days; however, this is not possible with dentistry due to dental procedures.

I verify that I have not traveled outside the U.S in the past 14 days to countries that have been affected by COVID-19
I verify that I have not traveled outside the U.S in the past 14 days to countries that have been affected by COVID-19

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

Email address

Your information will be encrypted.

Patient Dental and Registration and History

PATIENT INFORMATION

DENTAL INSURANCE

ASSIGNMENT AND RELEASE

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT

DENTAL HISTORY

HEALTH HISTORY

MEDICATIONS

ALLERGIES

UPDATES (To be filled in at future appointments)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

APPOINTMENT SCHEDULE ACKNOWLEDGEMENT

INSURANCE/BILLING POLICY

COVID-19 Pandemic Dental Treatment Consent From

DEBORAH YOUNG MAKERSON, DMD, PC REGINALD L. MAKERSON, DDS