New Patient Form

Smiles on Trindle Dental Care

Please correct the errors described below.

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.

WOMEN

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.

PATIENT REGISTRATION

REFERRAL INFORMATION

DENTAL INSURANCE INFORMATION

PRIMARY DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

DENTAL HEALTH RECORD

DENTAL CONCERNS & PREFERENCES

DENTAL HISTORY

AESTHETICS

Please mark if applies:

TMJ

SLEEP

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.

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”). I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers
  • Conduct normal health care operations such as quality assessments and physician certifications.

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at anytime to obtain a current copy of the 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.

Please list individuals’ names that we can release financial and medical information to:

Add another name:

Written Financial Policy

Thank you for choosing Smiles on Trindle Dental Care. Our primary mission is to provide the most professional and comprehensive dental care available. An important part of the mission is making the cost of treatment manageable for our patients by offering several payment options.

Payment Options:

  • Cash, Check, Visa, Discover, MasterCard, American Express, Health Savings, Care Credit, and Online Bill Pay
  • Monthly Payment Plan options are available through Care Credit (subject to credit approval).

Patients with Dental Insurance:

We realize how confusing the complexities of insurance can be. Dental insurance is not designed to pay in full for all dental care. This is a common misconception of those insured. The dental insurance is a contract between the insurance company and the patient, who bears the ultimate financial responsibility. Smiles on Trindle will work with you to understand your insurance coverage and submit claims on your behalf, but it is ultimately the patient’s responsibility to understand their specific plan.

Our office is in-network with various insurance companies. Those in-network fees, deductibles and coinsurances are set forth by the insurance company and plan guidelines. All deductibles and co-pays are collected at time of service

Self-pay Patients and Non-covered Services:

All service fees are collected at time of service and eligible for a 5% courtesy discount. Our fees are based upon a combination of our cost, our time and our constant dedication to supplying our patients with the highest of quality dental care.

Additional Office Charges:

  • $30 – No show/less than 24-hour notice for all cancelled preventative appointments
  • $50 – No show/less than 24-hour notice for all cancelled non preventative/procedural appointments
  • $35 – Returned check fee

Account billing statements will occur weekly with a 30-day remittance period. All accounts over 90 days past due will be considered for collections. Any account sent to collections will incur a 35% collections fee.

Should you have any questions regarding this financial agreement, please speak with our financial coordinator.

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.

INFORMED CONSENT FOR TREATMENT

1. Health Information

I agree to disclose all previous illnesses and medical history. Undisclosed medical information, current medications, allergies or illness are risk factors.

2. Drugs, latex and medicines

I understand that antibiotics and other medicines can cause allergic reactions and even life-threatening anaphylaxis. Also, some antibiotics interfere with birth-control pills. Latex allergy can cause rashes and itching. Epinephrine increases the heartbeat and, depending on my health, may be dangerous to me.

3. Needle stick

If someone is inadvertently stuck with a needle used on me, I consent to have blood drawn for analysis.

4. Fillings, Crowns and Un-anticipated Root Canals

Some teeth may need a root canal even after a simple filling. Fillings and crowns do take away tooth structure and a percentage of these teeth end up needing a root canal after the filling or crown is done.

5. Root Canals Can Fail

Root canals can fail and may require additional treatment or the tooth may not be salvageable and require extraction

6. Porcelain Crown, Veneers, Bonding and Cosmetic Fillings

Porcelain crowns, veneers, cosmetic bonding and composite fillings are aesthetically pleasing; however, I understand that if they chip or break after successfully in use, I am responsible for repairs or remakes. Once a crown, veneer, bonding or filling is placed, I understand the color cannot be changed.

7. Extractions and Surgery

I understand that all dental extractions or surgeries carry risks for example, a dry-socket following an extraction. Some risks are life threatening such as a post-surgical infection or anaphylaxis.

8. Fee for Additional or Specialty Care

I understand that I may need treatment beyond what was originally planned (a crowned tooth becomes painful and will need a root canal), or I may be referred to a specialist for additional care (root canal was not successful). I agree to be financially responsible for the additional or specialty care.

9. Insurance/Limitations of Insurance Coverage

I authorize Smiles on Trindle Dental Care to file claims on my behalf. There might be charges beyond what insurance will pay, deductible, copays or coinsurance that are my financial responsibility. I understand that what may be quoted as my portion (co-payment) is only an estimate. I agree to be financially responsible for what insurance does not cover.

10. Gum Treatments and Requesting “Just a Cleaning”

If I do not floss, smoke and/or have gum disease, I can expect to have a deteriorating gum condition. I agree that if I require gum treatment, I will not insist that I simply get a cleaning (prophylaxis).

11. Appointments

If I am more than 10 minutes late for my appointment, I will reschedule and pay a broken appointment fee.

12. 24 Hour Notice for Cancellations

I agree to give 24-hour notice for cancellations or pay the broken appointment fee. (See financially policy for amount)

13. Requesting Record Transfers

Upon finding a new dentist, I will give the office 24 hrs to transfer records and provided a signed records release to authorize the transfer of records.

I do not expect guarantees in dental care. I have read the above and consent to treatment.

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.

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