As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Dental Information

Medical Information

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Patient Screening

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Insurance: As a courtesy to all patients we will verify your dental insurance benefits, but you are responsible to know your plan coverage, exclusions, and limitations. Furthermore, you should be aware of non-covered benefits such as a missing tooth, clause downgraded limitations for fillings, and downgraded all porcelain crowns to porcelain metal crowns on molar teeth, frequency limits for exams, prophylaxis (normal cleanings), fluoride and x-rays, etc. The estimated amount not covered by your insurance is due at the time of treatment and may be paid by check, cash, or credit cards. We also offer a Care Credit financing program.

All estimates are subject to final approval by your dental insurance plan: therefore, the amount due is subject to change after final explanation of benefits have been paid.

INITIAL PAYMENT FOR DENTAL TREATMENT: Most plans are covered for clinical exam and normal cleaning (prophylaxis); no deductible is due for diagnostic or preventive treatment unless otherwise stated. Periodontal maintenance and deep cleanings are usually not covered at 100% like normal cleanings. There are some plans with co-insurance payment for x-rays and dental exams. Deductible for basic/major services customarily include fillings, crowns, extractions, root canal therapy, and periodontal treatment (including periodontal maintenance & deep cleanings).

Deductibles are usually $50 per individual up to $150 per family annually
$175 for any buildup & crown procedure. Some plans do not allow separate benefits for crowns and build-up. In such a case the patient is responsible for the full cost of the build-up.

RESIN-BASED COMPOSITE RESTORATIONS: (Fillings) Some dental insurance plans do not allow full benefits for composites (white fillings) performed on posterior teeth (back molars). The plan benefit will customarily pay for less expensive treatment -amalgam (silver/mercury based restoration). For the best of our patients, we place only composite (white) fillings. The difference is usually around $15 per filling and the patient is responsible for the difference in cost. Please ask if you need more information about composite (white) fillings.

PULP-CAP TREATMENT: (Medicament to protect the pulp chamber) Most dental plans do not allow additional benefits for pulp-cap treatment (this procedure in which the filling is very deep, close to the center of the tooth. The nearly exposed nerve is covered with a protective medication. The cost of this treatment is around $275 per tooth (depends on your insurance coverage) and the patient is responsible for payment at the time of treatment.

FINANCIAL CHARGES: All return checks are subject to a $25 fee. We reserve the right to apply a $20 rebilling fee and $25 late charges toward overdue financial agreements.

MISSED APPOINTMENTS: Please give us a call in advance if you need to reschedule or cancel your appointment. If you repeatedly miss schedule appointments without giving us a prior notice, you may be discharged from our practice.

TRANSFERRING RECORDS: You will need to request in writing, if you would like us to mail, fax, email, etc. any part of your records with Pope Family Dentistry. We need at least 8 working hours in advance to prepare your record to be transferred.

This is an Agreement between Pope Family Dentistry, as a provider of professional services and creditor, and the patient/ debtor named on this form. By reading and signing this agreement, you are agreeing and accepting this policy in full.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION; ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION; I UNDERSTAND AND AGREE TO ALL POLICIES OF POPE FAMILY DENTISTRY.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Primary Dental Insurance

Secondary Dental Insurance

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.