Patient Forms

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Patient's Name

Dental Insurance

**Please make sure we have a copy of your insurance card**

    Please upload a file

    Authorization: I have completed this form fully and completely, and certify that I am the patient or duly authorized general agent of the patient to furnish the information requested.

    I understand that even though I might have a form of insurance coverage, I am fully responsible for all payments at the time of service, including my deductible and co-pay which the insurance does not cover.

    I understand that my insurance carrier may pay less than the actual bill for services and I am financially responsible for the payment in full.

    I understand that where appropriate, credit bureau reports may be obtained. We accept MasterCard, Visa, American Express, Discover, cash and personal checks.

    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.

    Potential Risks and Limitations Of Dental Treatment

    As a rule, excellent dental results can be achieved with informed and cooperative patients. Thus, the following information is routinely supplied to anyone considering dental treatment in our office recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that dental treatment, like any treatment of the body, has some inherent risks and limitations. These risks and limitations usually do not contra-indicate treatment but should be considered in making the decision to submit dental treatment.

    Perfection is our goal. However, in dealing with human beings, and problems or growth and development, the ravages of dental disease, genetics and patient cooperation, achieving perfection is not always possible. Often a functionally and esthetically adequate result must be accepted. We will do everything within our capacity to insure the best possible care.

    Throughout life teeth are constantly changing. Periodic examinations should be made so any disease can be treated promptly. Frequent professional visits are the best insurance against serious dental disease. Decay or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Excellent oral hygiene and plaque removal is a must.

    On rare occasions the nerve of a tooth may die and become infected. A tooth that has been damaged by deep decay, a minor blow or extensive dental treatment can die over a long period of time. An undetected non-vital tooth may flare up during any dental treatment, and may require endodontics (root canal) treatment to maintain it. It may even have to be removed. There is also a risk that during or following treatment soreness or tenderness may occur in the temporomandibular joints (lower jaw joints).

    The total time for treatment can be delayed beyond our estimate. Treatment plans can change due to altered conditions which may surface during treatment. Decay which may appear small on x-ray, may be larger than anticipated resulting in much more extensive treatment.

    Informed Consent

    I understand that during treatment occasionally any of the above problems may occur. These can include but are not necessarily limited to: pain (discomfort), tooth mobility, tooth decay, devitalization (nerve loss), tooth and/or jaw changes, and injury resulting from the use of high speed dental equipment.

    I understand that treatment alternatives will be explained (including consequences of no treatment) as well as the preferred method of treatment for my mouth. I understand that for a successful result to lessen the dangers of complication, the following conditions are essential on my part:

    1. Excellent oral hygiene
    2. Proper diet controls
    3. Strict adherence to instructions
    4. Cooperation in keeping appointments

    I understand that there is no warranty or guarantee to my result and/or care, I also understand that I can, at any time, ask for and receive a full recital of all possible risk related to my treatment.

    In addition, I understand that treatment may be discontinued for patients who fail two appointments without prior notification: who are constantly late for their appointments and who continue to excessively cancel their appointments: who fail to practice acceptable oral hygiene: or who are uncooperative with staff providing care.

    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.

    Medical History

    Check if you have or have had problems with any of the following:

    Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Check the medications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to:

    List the other medications you are currently taking and what condition you are taking them for. Include vitamins, supplements, herbs and over the counter medications.

    Add Medication

    Check your current use of:

    To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

    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.

    Dental History and Patient Goals

    Dental History

    Check if you have or have had problems with the following:

    PATIENT GOALS

    PRIVACY PRACTICES ACKNOWLEDGEMENT (HIPAA)

    I have received the Notice of Privacy Practices and I have been provided the opportunity to review it.

    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.

    TCPA Consent

    You agree, in order for us to service our account or to collect any amounts you may owe, our organization's representatives, ancillary providers, HIPAA business associates, vendors, and the representatives or our debt collection agency, may contact you by telephone at any telephone numbers associated with your account, including wireless telephone numbers which could result in charges to you. Our organization's representatives, ancillary providers, HIPAA business associates, vendors, and the representatives of our debt collection agency may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing service, as applicable. I/We have read this disclosure and agree that the Lender/Creditor, its ancillary providers, HIPAA business associates, vendors, and its debt collection agents may contact me/us as described above.

    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.

    FINANCIAL POLICY AND PRIVACY AGREEMENT

    When we begin treatment, we make a commitment to provide you with the finest dental services possible. We are striving to help to create and preserve beautiful smiles for a lifetime.

    INSURANCE

    If you have dental insurance, we will do our best to estimate what your insurance will cover and ask you to pay what we estimate your insurance will not cover. This is only an estimate; we cannot understand completely the specifics of every insurance plan and the variations to each one. Because of this, there may be a balance owed by you after the insurance has payed, or you may also have a credit. You have our pledge that we will do our best to estimate as accurately as possible. You will be responsible for any balance your insurance does not cover.

    DUAL INSURANCE

    If you have dual insurance coverage, we cannot accurately estimate what the secondary insurance will pay and due to the time it takes the secondary insurance to pay, it can become very confusing for everyone. Because of this, we will file the secondary insurance for you, but ask that payment will be sent directly to you such that you are responsible for what the primary insurance does not cover.

    PAYMENT OPTIONS

    You may pay as you go - meaning pay your portion when the service is rendered. Some procedures may require multiple visits and you can split your portion over those visits. We may also be able to phase treatment such that it can become more affordable. We accept most credit cards, checks and cash.

    5% DISCOUNT

    If your treatment is over $1000 and if you pay in full at the beginning of treatment, you will be eligible for a 5% discount. If you have insurance, to be eligible for this, you will need to pay the entire amount less the 5% and the insurance payment will be sent to you.

    CARE CREDIT

    Our office has entered into an agreement with CARE CREDIT to offer six-month interest free payment option to qualified applicants.

    COLLECTION FEES

    Any and all fees that are generated by any liens filed or accounts turned over to the collection agency, is your responsibility.

    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.

    RELEASE OF INFORMATION FOR INSURANCE AND REFERRALS

    I authorize release of information to any referred physician, financially responsible party, insurance company, or federal payer as is appropriate for billing and receiving payment for any and all dental services provided from Christian R. Willard, D.D.S. and its personnel.

    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.

    I would prefer to be notified of my upcoming appointments by the following:

    (Please indicate which of these applies to your preference. You may choose as many as you like).

    Your information will be encrypted.

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