New Patient Digital Form "*" indicates required fields Step 1 of 3 33% PATIENT MEDICATIONS & ALLERGIESPatient NameDate of Birth MM slash DD slash YYYY Gender Male Female Other Do you have any allergies or adverse reactions to medication? If so, please list.Pharmacy Name:Pharmacy Number:List all medications you are currently taking:NameDose (mg, puffs, drops)Schedule (times/day) Add RemoveAre you under a physician’s care now? Yes No Have you ever had a major operation or hospitalization? Yes No Are you taking any medications, pills, or drugs? Yes No Do you currently take, or have you taken, Phen-fen or Redux? Yes No Have you ever taken medications that contain bisphosphonates such as Fosamax, Boniva, or Actonel? Yes No Do you use tobacco? Yes No Are you on a special diet? Yes No Do you use controlled substances? Yes No Women: Are you... Pregnant / Trying to get pregnant Nursing Taking birth control Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Other? PATIENT MEDICAL HISTORYPlease review the following medical systems:Do you have any history of diseases or disorders of the cardiovascular system (ex. Arrhythmia, Congenital Heart/Artery Disease, Heart Attack, Deep Vein Thrombosis, Stroke, Hypertension, etc.)? If so, please list.Do you have any history of diseases or disorders of the skeletal system (ex. Osteomyelitis, Leukemia, Arthritis, Osteoporosis, etc.)? If so, please list.Do you have any history of diseases or disorders of the muscular system (ex. Temporomandibular Joint Disorder, Muscular Dystrophy, Fibromyalgia, Myofascial Pain Syndrome, etc.)? If so, please list.Do you have any history of diseases or disorders of the nervous system (ex. Parkinson’s Disease, Multiple Sclerosis, Alzheimer’s Disease, Seizures, Vertigo, Trigeminal Neuralgia, Epilepsy, etc.) If so, please list.Do you have any history of diseases or disorders of the integumentary system (ex. Skin Cancer (Squamous Cell Carcinoma, Basal Cell Carcinoma, Melanoma), Skin Rash, Warts, etc.)? If so, please list.Do you have any history of diseases or disorders of the endocrine system (ex. Diabetes, Hypoglycemia, Addison’s Disease, Cushing’s Disease, Thyroid Disease, etc.)? If so, please list.Do you have any history of diseases or disorders of the lymphatic system (ex. Lymphatic Disease, Hodgkin’s Disease, Non-Hodgkin’s Lymphoma, etc.)? If so, please list.Do you have any history of diseases or disorders of the respiratory system (ex. Lung Cancer, Tuberculosis, Lung Disease, Emphysema, Asthma, Breathing Problems, Frequent Cough, Easily Winded, etc.)? If so, please list.Do you have any history of diseases or disorders of the digestive system (Cancer, GERD, IBS, Frequent Diarrhea, Stomach/Intestinal Disease, Hepatitis, Liver Disease, etc.)? If so, please list.Do you have any history of diseases or disorders of the urinary system (Kidney Disease, Renal Dialysis, Prostate Cancer, etc.)? If so, please list.Do you have any history of diseases or disorders of the reproductive system (Cancer, HIV/AIDS, Herpes, Sexually Transmitted Diseases, etc.)? If so, please list.Do you have any other diseases, disorders, or conditions not listed above? If so, please list.Patient InformationNamePreferred NameSex Male Female Prefer Not to Disclose AddressPhoneCityStateZipCell PhonePatient SSNDate of Birth MM slash DD slash YYYY Work PhoneEmail Address Check the appropriate box: Minor Single Married Divorced Widowed Separated Patient’s or Parent/Guardian’s EmployerEmployer AddressWork PhoneCityStateZipEmergency ContactPhoneREFERRAL INFORMATIONThank you for choosing Radiant Smiles Family and Cosmetic Dentistry as your dentist in Pineville, NC! To help us meet your entire dental healthcare needs, please fill out these forms completely. If you need assistance or have questions, please contact us and we’ll be happy to help! We also give out gift cards for referrals that have treatments. Referrals mean a lot! How did you hear about us? Google Direct Mailer Insurance Facebook Twitter Other How do you prefer to be contacted? Cell phone Home phone Email Other If referred by a patient/relative, whom may we thank for the referral? Responsible Party Information Person responsible for accountDate of Birth MM slash DD slash YYYY SSNAddressPhoneCityStateZipEmail Relationship to PatientInsurance Information Name of InsuredRelationship to PatientAddressPhoneCityStateZipEmail Insurance CompanyName of EmployerPolicy/ID NumberGroup NumberInsurance PhoneYour Comments : I have accurately answered the questions on this form to the best of my knowledge. I understand that incorrect information can be dangerous to my own or to the patient’s health. I am responsible for informing my dental office of any changes to my (or the patient’s) medical status. Signature of Patient, Parent or Guardian: Signature :Date MM slash DD slash YYYY FINANCIAL AGREEMENT AND OFFICE POLICIES In order to keep our fees as low as possible we have implemented the following policies. Please read the following information carefully to minimize billing and insurance problems. Payment: Payment is due in full for each appointment as services are rendered. The payment options are: Cash Credit Card Money Order Check – if paying by check, there will be a $25 returned check fee assessed to your account on all returned checks.In instances where the service to be provided is above $250, the patient will be asked to pay a non-refundable deposit of $100 to secure an appointment slot. If the patient does not cancel the appointment within 36 hours, the patient will lose this deposit. Dental Insurance: Dental insurance is a contract between you and your insurance company. All charges you incur are your responsibility regardless of your insurance coverage. There is no direct relationship between our office and your insurance company. Your insurance benefits are determined by the type and design of plan chosen by you and/or your employer and we are not party to this contract. We have no control over the terms of your contract or the determination of your benefits. We will file your primary dental insurance claims as a courtesy to you. We do NOT guarantee payment and are not responsible for providing you with the plan limitations, exclusions and provisions determined by your insurance company. You agree to pay any portion of the charges not covered by your insurance. We will file a pre-determination for recommended treatment when it is requested by you. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time. Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company. Untitled* I understand that if the patient does not have dental insurance, payment in full is expected on the day of service. Untitled* I understand that if the patient does have dental insurance, the responsible party will pay the patient estimated portion and deductible on the day of service: the insurance will be billed as a courtesy; however, I am aware, if the insurance does not pay within 60 days payment in full is expected from the responsible party. I understand it is my responsibility to know and understand my benefits, and the fees quoted in our office are only estimates. I am responsible for anything that my insurance does not cover. I understand that if my insurance company has not paid the balance in full within 60 days, the balance will automatically be transferred to my account and I will be responsible for the balance owed. Our office does not render services on the assumption that your treatment will be paid by your insurance company. Emergency Appointments: All emergency dental appointments must pay for the exam and x-ray when checking in. Any additional treatment or any dental services performed must be paid for in full at the time of service. Upon examination, your doctor will prepare a treatment plan. The treatment plan is only an estimate of the dental care required and should not be construed as a statement of actual charges. A plan may need updating after treatment has started as each procedure is unique. Missed Appointments: A missed appointment is defined as a cancellation, no-show or reschedule of an appointment with less than 24 hours’ notice. Our office requires 48 hours notifications if you are unable to keep your scheduled appointment. If less than 48 hours’ notice is given, a $25 fee will be charged to your account. Patients with two missed appointments will be asked to transfer their records to another practice. If any first time appointment is missed, the patient will not be seen by the practice for future appointments. Late Arrivals: We ask that you arrive 15 minutes prior to your scheduled appointment. If you arrive 15 minutes past your scheduled appointment time, you may be asked to reschedule. Monthly Statements: If you have a balance on your account, we will send you a monthly statement. It will show the previous balance, any new charges to the accounts, collections charge (if applicable) and any payments or credits applied to your account. Professional fees are the responsibility of the parent and/or guardian authorizing treatment; we cannot send statements to other persons. Collections Charge: Your account will be transferred to a collections agency once it is 60 days past due. The responsible party agrees to pay all attorney fees and court costs associated with collecting payment for services rendered. Collection fees of approximately 50% are added to the account when it is turned over to the agency. I grant my permission for you or your assignee to telephone me at home or at my workplace to discuss matters related to this form. I also agree to let this office leave messages concerning appointments and/or results on my answering machine or with a family member. I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information either electronically, by facsimile or paper form to my insurance carrier or any related entities that require such information. Effective Date: Once you signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the highest quality dental care using only the best material and technology available. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs. * I have read and understand the above policy and agree to abide by this policy. Patient Signature (OR parent/Guardian)Date MM slash DD slash YYYY ACKNOWLEDGEMENT OF RECEIPT - NOTICE OF PRIVACY PRACTICEOur “Notice of Privacy Practices” document provides detailed information about the use and disclosure of your protected health information. You have the right to review the “Notice of Privacy Practices” document prior to signing this consent form Radiant Smiles Family and Cosmetic Dentistry encourages you to read our Notice of Privacy Practice in full.Our “Notice of Privacy Practices” document is subject to change. You can obtain a copy of the current notice by contacting our organization and requesting that a revised copy be sent to you in the mail or given to you in person.I, AS THE PATIENT OR THE PATIENT’S PERSONAL REPRESENTATIVE, HAVE RECEIVED A COPY of Radiant Smiles Family and Cosmetic Dentistry “HIPPA NOTICE OF PRIVACY PRACTICES” document. If this acknowledgment of receipt is not obtained (i.e., emergency treatment situation), Radiant Smiles Family and Cosmetic Dentistry representative (witness) MUST document his/her good faith efforts to obtain the acknowledgment and the reason the acknowledgment was not obtained.(Signature of Patient, Personal Representative of Patient, or Legal Guardian of Patient)Date MM slash DD slash YYYY GOOD FAITH EFFORT AND REASON ACKNOWLEDGEMENT WAS NOT OBTAINED (DOCUMENTED BY Radiant Smiles Family and Cosmetic Dentistry)Patient refused to signPatient unable to signOther:PERSONAL REPRESENATIVE AUTHORIZATIONA personal representative is anyone that you would like for Radiant Smiles Family and Cosmetic Dentistry to release your patient information to, including, but not limited to, prescription refills and/or samples, reasons for a particular visit, billing information, etc. If there are no names listed below, we are assuming that you are declining your option to choose a personal representative. Upon doing so, please keep in mind that our office will not give out any information, including prescription refills, to anyone other than the patient or patient guardian.* I do not wish to select a personal representative I authorize the following individual(s) to serve as my/patient’s Personal Representative with full authority to access or authorize review, release and/or copying of my/patient’s medical records: 1234* I authorize Radiant Smiles Family and Cosmetic Dentistry to leave detailed information in my voicemail box. I do not authorize Radiant Smiles Family and Cosmetic Dentistry to leave detailed information in my voicemail box. I authorize Radiant Smiles Family and Cosmetic Dentistry to send information via text messaging I do not authorize Radiant Smiles Family and Cosmetic Dentistry to send information via text messaging. I authorize Radiant Smiles Family and Cosmetic Dentistry to send information via email messaging. I do not authorize Radiant Smiles Family and Cosmetic Dentistry to send information via email messaging I may revoke this request in writing at any time except to the extent that action based on this authorization has already taken place. (Signature of Patient, Personal Representative of Patient, or Legal Guardian of Patient)Date MM slash DD slash YYYY If forms have been completed by someone other than the patient, please print name here:Date MM slash DD slash YYYY Δ
