What is your Primary Care Physicians name & phone number? What is the date (or approximate date) of your last medical exam?
What MEDICATIONS or other substances are you taking or have you taken in the past 2 months?
Please indicate if you have experienced any of the following:
Please list any other parties who can have access to your health information: (This includes step-parents, grandparents and any other care takers who cen have access to this patient's health information):
I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.
I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.
I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and payment is due on the day services are rendered. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).
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.
WE SET ASIDE 90 MINUTES FOR OUR NEW PATIENT EXAMS, WE TAKE X-RAYS, PICTURES, DO AN ORAL CANCER SCREENING, PERIO CHART, AND COME UP WITH A CUSTOMIZED TREATMENT PLAN TO FIT YOUR DENTAL NEEDS.
PLEASE PLAN TO BE HERE FOR UP TO 2 HOURS. THIS ALLOWS DOCTOR AND TEAM ENOUGH TIME TO EVALUATE YOUR INDIVIDUAL ORAL HEALTH. THEN WE CAN SCHEDULE YOUR CLEANING AND ANY DENTAL WORK THAT MAY BE RECOMMENDED BY DR. SANFORD.
CANCELLATION AND NO SHOW POLICY REMINDER
Here at Dr. Susanne M. Sanford, D.D.S., we take pride in our commitment to providing quality care and patient satisfaction.
This letter is a reminder that as our patient, you have a responsibility to notify us in a timely manner (2 business days) of your need to cancel/ reschedule an appointment. This timely information allows us to reschedule other patients who are waiting to see the doctor.
We understand emergencies and sudden illnesses do occur which we will accommodate on a case by case basis. However if this seems to be a chronic occurrence, we reserve the right to charge a short notice/ no show fee of $50.00, or possible dismissal from the practice.
We feel privileged to be your dental provider and thank you for your understanding in this manner.
Sincerely, Dr. Susanne M. Sanford D.D.S
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