MEDICAL HEALTH HISTORY
Cancer or tumor
Heart ailment or angina
Heart murmur, mitral valve prolapse, heart defect
Pheumatic fever or rhematic heart disease
Artificial joint or valve
High or low blood pressure
Tuberculosis or other lung problems
Hepatitis or other liver disease
Epilepsy, seizures, or fainting spells
Herpes or cold sores
AIDS or HIV positive
Migraine headaches or frequent headaches
Anemia or blood disorders
Abnormal bleeding after extraction, surgery, or trauma
Hayfever or sinus trouble
Allergies or hives
Penicillin or other antibiotics
Codeine or other narcotics
Barbiturates, sedatives, or sleeping pills
Anticoagulants (blood thinners)
Antidepressants or tranquilizers
Insulin, Orinase, or other diabetes drug
Cortisone or other steroids
Osteoporosis (bone density) medicine
Other Medication List:
Do you require antibiotic prior to dental treatment?
May be pregnant
Expected delivery date:
Taking hormones or conraceptives
ALL ACCOUNTS ARE DUE AND PAYABLE AT THE TIME OF SERVICE. If a procedure requires multiple appointments , payment is required in full at the first appointment.
Care Credit monthly payment plans for qualifying patients.
Patient with insurance : The PATIENT is responsible for the ESTIMATE non-covered portion , procedures and/or deductibles at the time of the service. If the insurance company downgraded treatment fees / does not pay after 60 days , we will bill you directly for the full balance. If the insurance is terminated / lost before the completion of procedure , patient is responsible for the unpaid balance.
Parents accompanying their children are financially responsible for payment.
There is a $50.00 processing charge for an NSF Check or returned check.
Checks will not be accepted for new patients
There is a nominal charge of $20 for release of copies of x-rays.
Because instruments , chairs , and personnel are reserved exclusively for your appointment , there is a $50 CHARGE FOR CHANGED OR BROKEN APPOINTMENTS LESS THAN 24 HOURS IN ADVANCE.