Download Health Information - Azarko Dental Group

Patient Information
Patient Name: _________________________________________ Date:_____________________
Gender: _____
Family Status: _________Birth Date:
Phone (Home): ___
(Work):
___
Cell:
Employer:
Email:
Address:
__________Apt#
Street
City
Province
Postal Code
Health Information
Date of Last Dental Visit:
Reason for this visit:
Have you ever had any of the following? Please check those that apply:
AIDS
HIV
Allergies
Penicillin Allergy
Codeine Allergy
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive
Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Heart Surgery
Hepatitis A B C
High Blood
Pressure
Kidney Disease
Psychological
Disorders
Pacemaker
Pregnancy Due
Date:
Radiation
Treatment
Respiratory
Problems
Sinus Problems
Stomach
Problems
Stroke
Tuberculosis
Tumors
Ulcers
Other:
Have you ever had any complications following dental treatment?
If yes, please explain:
Yes
Yes
___________________
___________________
___________________
___________________
No
 Have you been admitted to a hospital or needed emergency care during the past two years?
If yes, please explain:
 Are you now under the care of a physician?
If yes, please explain:
List of Medications
Taking:
___________________
Yes
No
No
 Name of Physician: _______________________________________________ Phone:
 Do you have any health problems that need further clarification?
If yes, please explain:
Yes
No
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any
change in my health, I will inform the doctors at the next appointment without fail.
_________________________________________________________________ Date:
Signature of patient, parent or guardian
Referral Information
Whom may we thank for referring you to our practice?
Dental Office
Yellow Pages Phonebook
Yellow Pages Internet
Name of person or office referring you to our practice:
Google
Website
Other
__________________________________________
Spouse or Responsible Party Information
The following is for:
the patient's spouse
the person responsible for payment
Name: ,
Male
Female
Married
Single
Child
Other
Insurance Information
Name of Company:
Group/Policy Number:
Id/Certificate Number:
Policy Holder:
Date of Birth:
Consent for Services
Appointments:
Please help us maintain the operation of our office on sound principles so that we may assure you and other patients of
uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you; therefore at
least 24 HOURS NOTICE MUST be given if cancellation is absolutely necessary.
Payment of Fees:
This office is willing to accept direct payment from your dental plan for services which your plan covers.
If your dental plan does not cover the full cost of your treatment, you will be responsible for any difference between the
amount paid by your plan and the amount charged.
Your portion is then due and payable on the day of your appointment unless other financial arrangements have been made.
There will be a 2.5% administration fee per month on all accounts over 30 days old
You are responsible for providing necessary information in order for us to direct bill your insurance company as well as
informing us of any changes in this information.
General Release:
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not
knowingly omitted any information. I also authorize the communication of information related to the coverage of serviced
described in this form to the named doctor.
Consent:
I, the undersigned, hereby authorize the doctor to take x-rays, study models, photographs or any other diagnostic aids
deemed appropriate by the doctor to make a thorough diagnosis of the dental needs. I authorize the doctor to perform any
and all forms of treatment, medication and therapy that may be indicated and consent to the use of local anesthetic agents. I
understand the above statements regarding payment of fees and accept the responsibility for payment for dental services
provided by myself or my dependants, due and payable when services are rendered unless other financial arrangements have
been made.
I have read the above conditions of treatment and payment and agree to their content.
____________________________________________________ Date: _____________ Relationship to Patient:
Signature of patient, parent or guardian
_____________
Azarko Dental Group and Your Insurance Plan
***How they work together***
Azarko Dental Group is pleased to direct bill your dental plan for you to help with the cost of dental treatment. Please read
the following information to ensure the claims process will be simple.
100% is not 100% in Alberta and you will be required to pay the difference
There is no fee guide in Alberta. Your dental plan is on “their fee guide” which most of the time does not match/pay dental
offices fees. Therefore there is an amount you must pay out of your pocket on the day of service. We do “shop” around our
fees to ensure we are competitive. We do not charge more because of our clinics hours or because we are also the
emergency clinic.
So you accept my insurance, how much do they pay?
At Azarko Dental Group, we will accept your insurance plan, provided they will make payment to the dentist, as not all
insurance companies will. We work with several different benefit plans and although we maintain a breakdown of your dental
plan, at times insurance coverage will change. We may not be able to give you a guaranteed quote at the time of your visit:
but based on the information we have we can give you an estimate of costs. Please remember this is ONLY AN ESTIMATE.
We would be happy to send a pre-treatment authorization to your insurance company, should you want a more precise
amount of what your plan will pay. Please be aware of your dental plan details. Most dental plan you can access online.
Financial Options
Azarko Dental Group does require payment in full for your portion at the time of the service. We accept payments by Debit
card, Mastercard, Visa and American Express. WE DO NOT ACCEPT CHEQUES. If you are in need of an extended
financial option we do offer Health Smart. Health Smart is 0% interest financing option. Health Smart must be preapproved
prior to commencing any treatment.
I paid a portion, but now I have received a statement. Why?
Although our office is able to send claims electronically, not all insurance companies are set up to receive claims via this
method. It may be necessary to estimate your portion of treatment costs at the time of your visit. We base the estimate on
the most current information that we have of your plan, but after your insurance company has sent us payment there still may
be a portion owing. This may be as a result of many factors, such as, there may have been a deductible applied or you may
have received treatment from another office prior to treatment in our clinic or your percentages may be different depending on
the procedure, or you may have gone over your plans frequencies etc....
My insurance did not pay, what happens now?
Our clinic will bill your insurance company as a courtesy to you. Azarko Dental Group reserves the right to request payment in
full for services from you, should your plan not pay within 90 days. Although it is a rare situation that insurance companies do
not pay, it is important to know that you are ultimately responsible for all charges incurred at our office.
When will you NOT bill my insurance company?
We will not bill your dental plan if you present a new insurance policy after hours where we cannot confirm active coverage.
Please ensure you update your insurance information with the reception team at the time of reserving an appointment. In
addition we will not bill your dental plan directly should you choose to proceed with major treatment prior to us receiving the
predetermination. Once we receive your predetermination, at the initial appointment we will collect a deposit which will equal
½ of your total patient cost and the remainder of your cost at the insert appointment.
I have read and understood the Azarko Dental Group Insurance Policy for billing my insurance company.
Patient Signature
Date