Dayton Valley Dental Care Patient Forms

Please correct the errors described below.

Here are some guidelines to help you understand our office philosophy. To better serve your needs, we strive for a clear, mutual understanding at all times If Dr. Escobar feels a certain procedure is better served by another Dentist or Specialist, he will reefer you. Quality First! Full mouth x-rays are necessary and required for the complete diagnosis both periodontal and restorative needs. Dr. Escobar diagnoses what he feels you need, NOT what insurance pays for. In order to build a positive relationship with the patient, we do require that parents, relatives, and friends remain in the waiting room unto; the appropriate time. We appreciate the value of your time, and except for emergency situations, you can expect us to be on time for you. We will appreciate the same courtesy. Payment is due at the time of service. We accept personal checks, cash, Care Credit, Visa, American Express, Discover, and MasterCard. If you find it necessary to changer your appointment, we require 48 hours notice. Missed appointment charge is $50.00 for every hour we have reserved for you. By signing this form, you agree to our office policy.

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Information

***If Different from Physical Address***

Emergency Contact

Spouse or Responsible Party Information

Closest Relative Not Living With You

Employment Information

Referral Information

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Any appointments that are failed, cancelled, or rescheduled with less than 48 hours notice will incur a $50.00 service charge per hour reserved to the patient account. This fee must be paid in full prior to scheduling a future appointment

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. All patient portion will be due at time of service, this includes co-pays and deductible. Patients that carry Delta Dental will have fees due at the time of services rendered. This Office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. Please be aware that all balances are due within 45 days, regardless if insurance has paid or not. A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days. After 90 days, all accounts will be turned over to a third-party collection. Any accounts requiring this action will incur all collection and legal cost. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless object to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if a suit be instituted hereunder. I hereby authorize doctor or designated staff to take x-rays, study models, photograph and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon and to employ such assistance as required to provide proper care. I agree to use anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Medical History

If yes, please list name and dosage

Add medication/dosage

For Women, are you:

I understand the above information is necessary to provide with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency who may release such information to you. I will notify the doctor of any change in my health or medication. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Dental History

Welcome! So that we may provide you with the best possible care, please complete this medical/dental history form. All information is completely confidential.

Are you satisfied with your teeth's appearance?

Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgment*

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

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

You have my permission to discuss my dental appointments and treatment with the following people:

Add individual

For Office Use Only

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