Download 3-in-1 Form - All About Smiles Valley Dental

Patient Information
Patient Name: _____________________________________________________________ Date: __________
Last,
Gender:
Male
Female
First
MI
Family Status:
(Preferred Name)
Married
Single
Child
Divorced
Widowed
Date of Birth:_______________________________ Social Security #: __________________________________
Phone #’s Home: ___________________ Cell: _______________________ Work: __________________________
Address: Street ________________________________________________ Apt # ________________________
City ______________________________ State
_______________ Zip Code ______________________
Email: __________________________________________________________________________________
Emergency Contact: Name: _______________________________________ Phone: ______________________________
Health Information
Date of Last Dental Visit: _______________ Reason for this Visit: _________________________________________
Have you ever had any of the following? Please check those that apply:
⃝ Dental Anesth. Allergy
⃝ Latex Allergy
⃝ Metal Allergy
⃝ Sulfa Allergy
⃝ Penicillin Allergy
⃝ Erythromycin Allergy
⃝ Codeine Allergy
⃝ Aspirin
⃝ Allergies____________
⃝ Artificial Joints/Valves
⃝ Mitral Valve Prolapse
⃝ Rheumatic Fever
⃝ Coumadin
⃝ Stomach Problems
⃝ Bisphosphonate/Fosamax
⃝ Diabetes: Type_______
⃝ Cancer: Type________
⃝ Blood Disorder: ______
⃝ Anemia
⃝ HIV
⃝ Epilepsy
⃝ Eating Disorder
⃝ Head Injuries
⃝ Congenital Heart Def
⃝ Heart Disease
⃝ Heart Murmur
⃝ Pacemaker
⃝ High Blood Pressure
⃝ Low Blood Pressure
⃝ Kidney Disease
⃝ Liver Disease
⃝ Difficulty Breathing
⃝ Emphysema
⃝ Respiratory Problems
⃝ Arthritis
⃝ Jaundice
⃝ Radiation Treatment
⃝ Glaucoma
⃝ Seizures
⃝ Thyroid Problems
⃝ Sinus Problems
⃝ Other ____________
⃝ Stroke
⃝ Tuberculosis
⃝ Tumors
⃝ Ulcers
⃝ Herpes/Fever Blisters
⃝ Alcohol/Drug Abuse
⃝ Asthma
⃝ Mental Disorder
⃝ Nervous Disorder
⃝ Fainting
⃝ Hepatitis:
….A ⃝ B ⃝ or C ⃝
⃝ Phen-Fen
Please list any medications you are currently taking _______________________________________________________________________________
_________________________________________________________________________________________________________________________
Have you ever been admitted to a hospital or needed emergency care during the past two years? ⃝ YES ⃝NO
If YES, please explain; ______________________________________________________________________________________________________
Are you under the care of a physician? ⃝ YES ⃝NO
If YES, please explain; ______________________________________________________________________________________________________
Name of physician ______________________________________________________________ Phone _____________________________________
Do you have any health problems that need further clarification? ⃝ YES ⃝NO
If YES, please explain; ______________________________________________________________________________________________________
WOMEN: Any prescribed method of birth control? ⃝ YES ⃝NO, Are you pregnant? ⃝ YES ⃝NO Are you currently nursing? ⃝ YES ⃝NO
Dental History
Are you currently in pain? ⃝ YES ⃝NO Do your gums bleed? ⃝ YES ⃝NO Would you like whiter teeth? ⃝ YES ⃝NO
Do you like your smiles? ⃝ YES ⃝NO Any discomfort in jaw joint/ TMJ? ⃝ YES ⃝NO Do you use any form of tobacco? ⃝ 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 doctor at the next appointment without fail.
Signature ________________________________________________________________________________ Date ____________________________
Referral Information
Whom may we thank for referring you to our practice? _____________________________________________________________________________
Parent or Guardian Information
Name: Last ___________________________________ First ____________________________Middle ________________________
Social Security #: ___________________________________________ Date of Birth: _______________________________________
Phone#: _______________________________Work/Cell#: ____________________________________________________________
Address: Street ________________________________________________________ Apt# __________________________________
City _______________________________________ State _________________________ Zip Code___________________
Employment Information
Employer Name: ______________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Insurance Information
Primary
Insurance Carrier Name: _________________________________ Address for Insurance: __________________________________
Name of Insured: ___________________________________ ________________________________ Is insured a patient
Y
N
Insured’s Birth Date: __________________________ID# __________________________ Group# __________________________ _
Insured’s Employer: ___________________________________________________________________________________________
Secondary
Name of Insured: __________________________________________________________________ _ Is insured a patient
Y
N
Insured’s Birth Date: _________________________ID# ____________________Group# ______________ _____________________
Insured’s Employer____________________________________________________________________________________________
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 patient for the
cost incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash or credit card at the time services
are performed.
This office reserves the right to bill for missed or cancelled appointments with less than 24 hours’ notice.
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. This office will help prepare the patients 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.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days and a late fee of $25 will be imposed,
unless previous financial arrangements are made. If my account is passed on to an outside collection agency the account holder will be responsible for the 30%
imposed to collect the balance.
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. I further agree that the reasonable value of said services shall be as billed unless objected 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 attorney fees if suit be instituted hereunder.
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.
_________________________________________________________ Date__________________ Relationship to Patient___________________________________
Signature of Patient, Parent or Guardian
Sara Reausaw, D.M.D., PC
4215 Berniece St., Rapid City, SD 57703
605-343-6691
Our goal is to provide quality dental care in a timely manner. In order to do so, we have had to
implement an appointment/cancellation policy. This policy enables us to better utilize available
appointments for our patients in need of dental care.
Cancellation of an Appointment:
In order to be respectful of the dental needs of other patients, please be courteous and call All About
Smiles promptly if you are unable to attend an appointment. This time will be reallocated to someone
who is in urgent need of treatment. If it is necessary to cancel your scheduled appointment, we
require that you call at least 24 hours in advance, and calling early in the day is appreciated.
Appointments are in high demand, and your early cancellation will give another person the possibility
to have access to timely medical care.
How to Cancel Your Appointment:
To cancel appointments, please call 605-343-6691. If you do not reach the receptionist you may leave
a detailed message on the voice mail. If you would like to reschedule your appointment, please be
sure to leave us your phone number and let us know the best time to return your call.
Late Cancellations:
Late cancellations will be considered as a "no-show".
No-Show Policy
A "no-show" is someone who misses an appointment without cancelling it in an adequate manner.
"No-shows" inconvenience those individuals who need access to dental care in a timely manner. A
failure to present at the time of a scheduled appointment will be recorded in the patient's chart as a
"no-show". The first time there is a "no-show", there will be no charge to the patient. Any additional
"no-show" will result in a fee of $45.00 billed to the patient's account. After three “no-show” the
patient will be dismissed from our practice.
Signature___________________________________________________ Date_________________