Leesburg: New Patient Form Step 1 of 7 14% Welcome to Smile Design!Patient Information (Confidential)Date:* Date Format: MM slash DD slash YYYY How did you hear about our office?Patient Name:* First Middle Last Preferred Name:Birth Date: Date Format: MM slash DD slash YYYY Social Security #:*Gender*MFMarital StatusMinorSingleMarriedDivorcedOtherOtherGuarantor/Resp. Party (Minors):Guarantor/Resp. Party SS#Birth Date: Date Format: MM slash DD slash YYYY Home Address* Street City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home*CellWork/OtherEmail Address* Your e-mail address is used for appointment reminders, monthly promotions, follow ups, and newsletters. If at any time you wish to OPT out of any or all of these services, please contact the office.Emergency Contact:Phone: Insurance InformationSubscriber Name* Last First M. I. Birth Date: Date Format: MM slash DD slash YYYY ID/SS#:Group #:Insurance Company Name:Phone #:Employer:Phone:Address Street City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Medical HistoryAre you under medical treatment now?YesNoIf yes, please explain:Primary Care Physician:Phone:Specialty Care Physician:Phone:Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?YesNoIf yes, please explain:ConditionYear Are you taking any medication(s) including non-prescription medicine?YesNoIf yes, what medication(s) are you taking? Do you need to pre-medicate with antibiotics?YesNoDo you use tobacco?YesNoDo you use controlled substances?YesNoAre you allergic to or have you had any reactions to the following? Barbiturates Local Anesthetics (eg. Novacaine) Latex Rubber Iodine Penicillin or any other antibiotics Sulfa Drugs Sedatives Any Metals (e.g. nickel, mercury, etc.) Aspirin Other (please list) Other (please list) Women Only: a) Are you pregnant or think you may be pregnant?YesNob) Are you nursing?YesNoc) Are you taking oral contraceptives?YesNoDo you have or have you had any of the following? High Blood Pressure Stroke Liver Disease Heart Attack Easily Winded Hepatitis/Jaundice Mitral Valve Prolapse Heart Trouble Leukemia Heart Murmur Frequently tired Cancer Low Blood Pressure Angina Radiation Therapy Heart Disease Chest Pains Recent Weight Loss Cardiac Pacemaker Thyroid Problem Fainting/Seizures Rheumatic Fever Kidney Disease Epilepsy/Convulsions Arthritis Diabetes Tuberculosis Anemia Asthma Respiratory Problems Glaucoma Emphysema Hay Fever/Allergies Swollen Ankles Aids/HIV Infection Sexually Transmitted Diseases Other Joint Replacement/Implant Stomach Troubles/Ulcers Other (please list) Do you have a Living Will?YesNoIf no, who will you appoint as your proxy in the event that you are unable to make your own medical decisions?Contact #:Relationship: Patient Dental HistoryWhat is the reason for your visit today?Is there is anything you would like to change about your smile, what would it be?Do your gums bleed while brushing or flossing?YesNoDo you feel pain to any of your teeth?YesNoAre your teeth sensitive to hot or cold liquids/foods?YesNoHave you ever had any difficult extractions in the past?YesNoAre your teeth sensitive to sweet or sour liquids/foods?YesNoHave you ever had prolonged bleeding following extractions?YesNoDo you bite your lips or cheeks frequently?YesNoHave you had orthodontic treatment?YesNoDo you have any sores or lumps in or near your mouth?YesNoDo you have (please check) dentures partials implants Have you ever had any head, neck or jaw injuries?YesNoHave you had oral hygiene instructions?YesNoHave you ever experienced clicking , pain, or difficulty opening/closing in relation to your jaw?YesNoHave you had any periodontal treatment? (please check)YesNoDo you have frequent headaches?YesNo Gingivitis Root Scalings Perio Maintenance Arestin (antibiotics) Do you clench or grind your teeth?YesNoCONSENT 1. I *hereby authorize the doctor and/or staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis. 2. I authorize the doctor to perform all recommended treatment mutually agreed upon. I also agree to the use of appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk. 3. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine. As stated in the “Payment Policy” form, payment is due and payable at the time services are rendered unless other arrangements have been made. (See form for additional information). 4. I understand that a $50 fee per 30 minutes for the duration of your appointment time reserved, will be assessed to your account for any missed appointments. Should I need to cancel or change any appointment, I understand that I need to give the office 48 business hours notice. 5. I understand that it is my responsibility to advise your office of any changes in the information contained in this form. Patient/Resp. Party:*Relationship to Patient:*Date:* Date Format: MM slash DD slash YYYY Release of Information Consent FormI* have read and understood the HIPAA Notice of Privacy Practices that was provided to me by Smile Design Dentistry. However, In the event that I may need them to do so, I grant permission for Smile Design Dentistry and or staff to: (Please Check one of the following):*1- Discuss any aspect of my treatment and or needs with my: Spouse, Parent (if patient is over 18), Other2- Have the above designated person, pick up any dental appliances, x-rays or dental records on my behalf.3- I do not wish to have my information discussed with anyone outside of the parameters of Health Insurance Portability and Accountability Act of 1996.Spouse(initial)Parent (if patient is over 18)(initial)Other Name(initial)*(initial)Patient - Signature*Date* Date Format: MM slash DD slash YYYY Smile Design Dentistry Cosmetic and Family Practice Our Policy of Care and Payment Ensuring that our patients receive high quality care is the goal of our practice! We strive to see every patient on time, however emergencies can delay the schedule occasionally. We thank you for your understanding. Payment Options Cash or Check Debits Cards (with Visa/MasterCard logo) Major Credit Cards (MasterCard, Visa, Amex, Discover) HSA/Flex Spending Debit Cards (with Visa/MasterCard logo) Care Credit (interest free financing available) Citi Bank Health Card Lending Club Simple Pay Applying for Care Credit and similar Payment Plans only takes a few minutes, and there is NO fee to apply. Broken Appointments Please call the office 48 hours (business days) in advance if you need to change or cancel your appointment with our office. We understand that there extenuating circumstances at times but this will allow us to better serve other patients needing to get an appointment and is greatly appreciated. A $50.00 set up and sterilization or broken appointment fee may be assessed if the appointment is broken without notice. Insurance Agreement This agreement is made between the undersigned patient below and Smile Design Dentistry. This form must be read and signed by the patient or the responsible party before the practice can accept payments directly from your insurance carrier. Patient/responsible party understands and agrees that he/she is responsible for all treatment fees on the patient’s account regardless of insurance estimates. Patient/responsible party understands and agrees that if for any reason your insurance carrier fails to pay the estimated portion that you are responsible for all balances on the account. Balances over 90 days are subject to be placed in collection’s that will include a 33% admin fee. We accept and file insurance as a courtesy to our patients and insurance estimates are not a guarantee of payment by your insurance carrier. All insurance policies are not the same and it is the patient/responsible party’s responsibility to understand their policy.*Patient/Responsible Party Signature* Date Format: MM slash DD slash YYYY Date Smile Design Dentistry Cosmetic and Family Practice Patient Consent for Use of Credit Cards, Debit Card, and Financing Disclosure of Protected Health Information It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies, when requested, to facilitate your payment. Services that are performed that are paid with a credit card, debit card, or financing third-party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Smile Design Dentistry to use and disclose my protected health information to any Credit Card Entity, Bank or Financing Company when they request such information to process an account and assist with payment.I will not challenge such credit, debit, or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise. I agree that this non credit card challenge agreement is irrevocable.*Signature of Patient or Legal Guardian* Date Format: MM slash DD slash YYYY Date
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