New Patient Information

Patient's Name

Date of Birth

Date Created

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

If yes, Please Explain

Women: Are you...

Are you allergic to any of the following?

Aspirin

Metal

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

Other

If other, Please specify

Have you ever had any serious illness not listed above?

Comments

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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 of Patient, Parent or Guardian

Date

PATIENT REGISTRATION

First Name

Last Name

Middle Initial

Patient Is

Policy Holder

Responsible Party

Preferred Name

Responsible Party (if some other than the patient)

First Name

Last Name

Middle Initial

Address

Address 2

City

State

Zip

Home Phone

Work Phone

Ext.

Cell Phone

Birthdate

Soc Sec. No.

Drivers License

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Patient Information

Address

Address 2

City

State

Zip

Home Phone

Work Phone

Ext.

Cell Phone

Birthdate

Age

Soc. Sec. No.

Driver's License

Email address

I would like to receive correspondences via e-mail.

Medicaid ID

Employer ID

Carrier ID

Pref. Dentist

Pref. Pharmacy

Pref. Hyg.

Referred By

Previous Dentist

Emergency Contact

Emergency Contact #

PRIMARY INSURANCE INFORMATION

Name of Insured

Insured Soc. Sec.

Insured Date of Birth

Employer

Address

Address 2

City

State

Zip

Ins. Company

Address

Address 2

City

State

Zip

Rem. Benefits

Rem. Deductions

SECONDARY INSURANCE INFORMATION

Name of Insured

Insured Soc. Sec.

Insured Date of Birth

Employer

Address

Address 2

City

State

Zip

Ins. Company

Address

Address 2

City

State

Zip

Rem. Benefits

Rem. Deductions

General consent for Dental Treatment

Dr. Suman Reddivari / Dr. Gaurav Malik

Patient Name

Birthdate

I give consent for myself/my child to receive dental treatment deemed necessary by the providers at the Southbridge Family Dental. These procedures include, but are not limited to; examinations, oral prophylaxes (cleanings), fluoride treatments, sealants, restorations (amalgam or composite fillings and crowns), periodontal (gum) treatments, endodontic (root canal) treatments, extractions, and the use of local anesthetics. I understand that the use of local anesthetics carries a small risk for swelling, bruising, allergic reaction, changes in pain perception, or prolonged anesthesia. This consent shall be considered in effect until rescinded or revoked.

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 & Relationship

Date

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Section A: Patient Giving Consent

Name

Address

Telephone

Section B: To The Patient - Please Read The Following Statement 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:

Southbridge Family Dental

(305 Main St, Southbridge, MA 01550)

RIGHT TO REVOKE: You will have the right to revoke this Consent at anytime by giving us written notice of your revocation submitted to Superstition Springs Endodontics as 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.

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 health care operations.

Name / Signature

Date

If this Consent is being signed by a personal representative on behalf of the patient, please complete the following:

Personal Representative Name

Relationship to Patient

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

REVOCATION OF CONSENT: I remove my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my Consent will not effect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

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

DENTAL DIMENSIONS FINANCIAL OPTIONS AND AGREEMENT

Thank you for choosing us for optimal oral health care. We have found that our patients appreciate knowing exactly what to expect from us both from a philosophy aspect and a financial aspect. Therefore we prefer to inform our patients of these before we begin treatment.

Financial Arrangements: We offer the following methods of payment for services provided. This will allow us to focus on our specialty. providing you with superior customer service and optimal dentistry in a comfortable environment using up-to-date materials while keeping our fees as affordable as possible.

1. Cash. Check. Debit Card. Master Card. Visa. American Express & Discover Accepted.

Payments in full is due when services are performed unless financial arrangements have been made prior to treatment.

2. Dental Financial Plan- CareCredit

We have made arrangements with a company that will finance your dental work with approved credit. This will allow you to complete your dental work without delay. make no initial payment and have low monthly payments with interest free options. Please see the receptions desk for more information.

Dental Insurances

Most dental insurance companies will not cover 100% of all dental expenses. Your portion. not covered by insurance. is due at the time of treatment performed. Please understand that dental insurance is contract between the patient and the insurance carrier. and not between the insurance carrier and the dentist. The patient is still the responsible party regarding dental fees.

Dental Insurance Estimate

Based on the information we have from your insurance company, we will ESTIMATE your portion of dental fees and payment will be due at the time of service. If there is a balance due after your insurance company pays their portion. you will be billed for any unpaid amount. You are responsible for any charges exceeding your benefits.

Appointments and Timeliness

Please remember that your appointments are reserved specifically for you. We are committed to seeing you on time and request that you arrive on time for your visits as well. We want to ensure all patients are seen when promised. We request that at least 48 hour notice be given if an appointment needs to be rescheduled. Missed appointments ( no shows) and short notice cancellation ( less than 48 hour notice) may be subject to charge commensurate with the time reserved for treatment. ($50 per hour).

Treatment Fee Estimates

Dental treatment fees given are based on the treatment anticipated at the initial comprehensive examination. Some teeth may have hidden decay or fractures. affected nerves or other unanticipated conditions requiring more extensive dental treatment. In situations 11·here additional charges are involved. we will explain the reason for additional treatment needed. Our financial coordinator will discuss the additional fees and financial arrangements involved.

Interest

A 1.5 % monthly interest charge (18% APR) will be applied to ALL BALANCES OVER 30 DAYS PAST DUE.

Returned checks

A $40.00 charge will be applied to all returned checks.

PLEASE FEEL FREE TO CONTACT US IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING DENTAL TREATMENT OR FINANCIAL ARRANGEMENTS.

I understand and agree to the following Financial Policies listed above:

Signature of Patient / Responsible Party

Date

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