New Patient Forms

MEDICAL HISTORY FORM

Date

Name

Last

First

Middle

Preferred Name

Address

Street

City

State

Zip Code

SS #

Home Phone

Cell Phone

Employer

Work Phone

Date of Birth

Height

Weight

Name of Spouse or Parent

Their Employer

Their SS#

Their DOB

Their Work Phone

Who to contact in case of emergency?

Phone

Refered By

For the following, choose yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your visit you will be asked some questions about your responses to this questionnaire and additional questions concerning your health.

3. My last physical examination was on

If so, what is the condition being treated?

5. The name and phone # of my physician(s)

If so what medicine(s) are you taking?

If so, for what condition?

If selected, Date of Heart Attack

If selected, Date of Tuberculosis

If selected, Date of Joint Replacement

Other

12. Are you allergic or have you had a reaction to:

A. Local anesthetics

Yes No

B. Penicillin

Yes No

C. Other antibiotics:

Yes No

Please List

D. Sulfa drugs

Yes No

E. Barbiturates, sedatives, or sleeping pills

Yes No

F. Codeine or other narcotics

Yes No

G. Latex

Yes No

H. Other

Yes No

Please list other allergic reactions

If so, explain

Women

Chief Dental Complaint

Due to safety concerns, only the patient being treated is allowed in the treatment room. Please discuss special considerations (for example, one parent accompanying a child) with a staff member prior to scheduling an appointment.

Minor patients (those below the age of 19) must have a parent or guardian present in our facility during all treatment appointments.

If you need to cancel your appointment, we must receive notice at least 24 hours in advance. This allows us the opportunity to schedule another patient. It is our policy to dismiss patients after 3 broken appointments without 24 hours notice.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

I hereby consent to dental treatment by the Monrovia Family Dentistry team. I understand that my treatment options depend on my current oral health conditions. I will thoroughly discuss and understand the risks, benefits and alternatives for my dental treatment before I allow the dental team to begin treatment.

Signature of Parent or Guardian

MONROVIA FAMILY DENTISTRY INSURANCE INFORMATION & POLICIES

In order to better serve you and obtain the best possible benefits from your dental insurance company, please carefully read the following and answer as accurately as possible. Don't hesitate to ask for help if you have questions. We will be happy to assist you.

Person Responsible For This Account

Daytime Phone #

Driver's License #

Responsible Person's Employer

DOB

SS#

If you have dental insurance, please fill out below and please know that if you have a deductible that has not been met, or a copay, we expect payment at the time of service. We will estimate your copay to be 20% if you are not sure what it may be. We would like to make a copy of your card if you have one.

Primary Carrier ( subscriber - is the name of person on contract)

Employer

Subscriber Name

Subscriber Birthday

Subscriber Daytime Phone #

Subscriber SS #

Contract #

Group #

Full Name of Insurance Co.

Address (if known)

Phone # (if known)

Secondary Carrier ( subscriber - is the name of person on contract)

Employer

Subscriber Name

Subscriber Birthday

Subscriber Daytime Phone #

Subscriber SS #

Contract #

Group #

Full Name of Insurance Co.

Address (if known)

Phone # (if known)

We want you to understand that your dental plan probably will not cover the total cost of your services. Most plans pay between 50 & 80% of the total. You must consider that your maximum yearly benefit, copay and deductible (if any), all enter into the final payment estimation. We cannot always answer specific questions about your benefits or predict insurance coverage because plans may vary according to the contracts involved. Your employer (plan sponsor) is usually the best source to obtain specific information about your plan.

It is your responsibility to be familiar with the specifications of your insurance provider's coverage. Some restorative materials are covered at different levels by insurance providers. For example, composite (white) fillings and porcelain (white) crowns on back teeth may require more out-of-pocket expense than amalgam (metal) fillings and metal crowns.

I have read the above and answered the questions to the best of my ability.

Signature

Date

FINANCIAL POLICY

Fees: Fees are considered to be those prevailing in this dental community for the services of a general dentist. We will always be happy to discuss fees with you, and will provide an estimate of proposed fees for any procedure upon request.

Appointment Cancellation Fee: Appointments cancelled without 24 hours' notice or no shows are subject to a $20 fee per 30 minutes of scheduled appointment time.

Payment: We request payment for office charges and co-pays at time of service. In reference to your insurance, you are responsible for co-pays and deductibles depending on the type of insurance and insurance carrier. We accept cash, check, debit and credit card (MasterCard, Visa and Discovery) payments. If the insurance claim has not been paid within 60 days, we ask that you pay the balance using one of the above payment methods.

Finance Charges: If an account balance has not been paid within 60 days from the date of service or from payment or non-payment of insurance, we will begin charging finance charges of 1.5% per month (18% annually) on the unpaid balance. Finance charges will accrue each month on the unpaid balance until payment is received in full.

Collection Practices: You agree, in order for us to service your account or collect monies you may owe, Monrovia Family Dentistry, and/ or our agents may contact you by telephone at any telephone number associated with your account, including cell phone numbers, which could result in charges to you. We may also contact you by sending text messages or email, using any email addresses you provide to use. Methods of contact may include using prerecorded/ artificial voice messages and/ or use of automatic dialing devices, as applicable.

It should be understood that your insurance policy is an agreement between you and your Insurance company, your dental bill Is an agreement between you and your dentist. You are responsible for full payment, regardless of the status of your insurance claim.

Insurance companies have a schedule of fees, which they will pay. Your dentist's fee may be more or less than the schedule of fees of your insurance company. However, you are responsible for the FULL payment of your account and for questioning your insurance company about delays in payment and the amounts they pay. In the event we turn your account over to a collection agency or attorney for collection, you will be responsible for the collection agency fees (33.33%), and/or court cost and reasonable attorney fees.

If you have any questions about payment options or financial responsibilities, please contact our office.

I/we have read, understand and agree to the provisions of this financial policy.

Signature of Patient or Person Financially Responsible

Date

MONROVIA FAMILY DENTISTRY

1920 SLAUGHTER ROAD
MADISON, ALABAMA 35758
(256) 830-2095

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse To Sign This Acknowledgement*

I have received a copy of this office's Notice of Privacy Practices.

Print Name

Signature

Date

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Please Specify

This form does not constitute legal advice, and covers only federal, not state, law in effect or proposed as of August 14, 2003. Subsequent law changes may require Form revision.

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