PATIENT INFORMATION
MEDICAL HEALTH HISTORY
FINANCIAL AGREEMENT
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 Pacemaker Tuberculosis or other lung problems Kidney disease Hepatitis or other liver disease Alcoholism Blood transfusion Diabetes Neurologic condition Epilepsy, seizures, or fainting spells Emotional condition Arthritis 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 Asthma
yes no
Latex materials Penicillin or other antibiotics Local anesthetics("Novocain") Codeine or other narcotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin Other:
Aspirin Anticoagulants (blood thinners) Antidepressants or tranquilizers Insulin, Orinase, or other diabetes drug Nitroglycerin Cortisone or other steroids Osteoporosis (bone density) medicine Other Medication List:
Do you require antibiotic prior to dental treatment? yes no
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.
Cash MasterCard Visa Novus/Discover American Express 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.