Patient
* If child, provide parent/guardian name(s)
** If student, please complete:
Please check preferred contact phone:
In case of emergency, please provide information for the nearest relative or designated contact person not at the patient's address:
Subscriber
Female Patients
All Patients: Do you have, or have you ever had any of the following? (Check all that apply):
All Patients: Are you allergic to or have you ever had any reaction to the following (check all that apply):
All Patients: Are you currently taking any of the following (check all that apply):
Add Drug Name
I understand the importance of a truthful health history and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.
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.
By signing below, I acknowledge that I have read and understand the ALL statements mentioned in this new patient packet.
I agree that the dental practice may communicate with me electronically at the email address below.
I am aware that there is some level of risk that third parties might be able to read unencrypted emails.
I am responsible for providing the dental practice any updates to my email address.
I can withdraw my consent to electronic communications by calling the office at 281-859-9073.
I have received a copy of this office's Notice of Privacy Practices.
By signing this form, you will consent to our and disclosure of you protected health information as detailed in our Notice of Privacy Practices.
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
We are committed to providing you with the best care possible to achieve total oral health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines.
Dear Valued Patient:Dental insurance is the most helpful as well and most misunderstood item in dental treatment today. Let us clear up some common misconceptions about your dental insurance.
Dental insurance is a contract purchased by your employer for your benefit. It has NO CONNECTION with our office. The extent of coverage and benefits provided varies greatly from company to company, and sometimes even within a company. It has absolutely nothing to do with services provided by the dentist and the fee charged for these services.
We will make every effort possible to assist you with your personal insurance coverage. As a courtesy, we will prepare and submit your insurance claims and will also provide estimates of expected insurance benefits. Estimates of personal financial responsibility for your dentistry will also be provided. Co-payments will be due at the time of treatment unless prior arrangements have been made. Since insurance estimates are not totally accurate, any overpayment will be refunded to you immediately. Any remaining balance may be funded when you receive your next statement. Should no insurance payment be made within sixty days of the submitted claim, the charges will become your sole responsibility. We will still continue to aid you in any way possible with your insurance.
If you have any questions pertaining to dental insurance, please feel free to talk with our front office staff.
By signing below I acknowledge I have read and understand the guidelines above.
Please answer the following questions by checking "yes" or "no" for each one
Snoring (Do you snore loudly?)
Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)
Observed Apnea (Has anyone observed that you stop breathing, or choke or grasp during your sleep?)
High Blood Pressure (Do you have or are you being treated for high blood pressure?)
BMI (Is your body mass index more than 35 kg per m2?)
Age (Are you older than 50 years?)
Neck Circumference (Is your neck circumference greater than 40 cm [15.75]?)
Gender (Are you male?)
Score 1 point for each positive response.
Scoring interpretation: 0 to 2 = low risk, 3 or 4 = intermediate risk, > or = 5 = high risk.
Your information will be encrypted.
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