New Patient Paperwork

Patient Information

Emergency Contact

Employment

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Consent to Contact

You agree, in order for us (or any agency working on our behalf) to service our account, to notify you
of information pertaining to your account or medical condition or for the purposes of collection we may
contact you by telephone at any number provided by you, including wireless telephone numbers.
We may also contact you via email or text message using any email you provide. Methods of contact
may include pre recorded and artificial voice messages and or use of automated dialing services.

Authorization for Dental Treatment Informed Consent

I herby authorize Dr. Harris and his associates to provide dental services, prescribe, dispense and/or adminster any drugs, medications, antibiotics and local anesthetics that him and his associates deem, in their professional judgement, necessary or appropriate in my care.

 

I am informed and fully understand that there are inherent risks involved in the administration of any drug, medication, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment and extractions (tooth removal). The most common risk can include but are not limited to: bleeding, swelling, discomfort, stiff jaws, infection, aspiration, parethesia, nerve distrubance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest.

I realize that it is mandatory that I follow any instructions given by the dentist and/or his associates and take any medication as directed.

 

Alternative treatment options, inlcuding no treatment, will be dicsussed. No guarantees will be made as to results of treatment. A full explanation of all complications is available to me upon request from my detist.

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA

Financial Agreement

Thank you for selecting Patriot Family Dental as your healthcare provider. We are honored by your choice and we are committed to providing you with the highest quality healthcare.

We ask that you provide us with the most correct and updated information about your insurance. You will be responsible for any charges incurred if the information provided is not correct.

Your dental benefits are based upon a contract made between you and an insurance company. If you have any questions regarding your dental benefits, please contact your employer or dental insurance directly. Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you.

We estimate your portion based on the most up to date information we have, but it is only an estimate. If you would like to know your exact insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment. This does delay treatment but will give you the exact out of pocket figures you may require. This can also change due to deductible information or changes to your policy.

We bill your insurance as a courtesy. If insurance does not pay in 90 days, we reserve the right to request payment in full for services from you and let you collect the insurance funds that are due you.

This is rare but it is important that you recognize that the insurance you have is a legal contract between You and your insurance company. Our office is not and cannot be a part of that legal contract.

Ultimately, you are responsible for all charges incurred at our office.

We require payment in full for your portion at the time of service. We accept..MasterCard, Visa, American Express, cash, checks. If you are in need of an extended finance option, we also work with CareCredit which offers 6 months or 12 months “deferred interest” or longer financing with interest.

A specific amount of time is reserved for you, and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hour advance notice to avoid broken appointment fees. After 2 rescheduled appointments a deposit may be required to reserve your future appointments.

Patients may also incur and are responsible for the payment of additional charges. These other charges could include charges for returned checks and any cost associated with collection of patient balances.

We welcome you to our office and look forward to helping you get the healthy, beautiful smile you've always wanted.

By my signature below, I hereby authorize the Doctors and Staff associated with Patriot Family Dental to release medical and other information acquired in the course of my examination and or treatment to the necessary insurance companies and third party contracts.

Cancellation and No-Show Policy

Office hours are by appointment and we do value your time. This office is a private practice dental office and not a dental “clinic. “Appointment time is reserved for you alone. Where appropriate, we prefer to schedule longer appointments so we can complete as much needed dental treatment as possible during one appointment. We feel this type of scheduling will cause minimal disruption to your daily schedule and will provide efficiency in completing your dental care. When you make an appointment, please be sure that you will be able to keep it. Morning appointments may be best for more complicated procedures.

Emergencies and unforeseen patient treatment problems may arise, causing schedule changes. Emergencies are unexpected and seem to come at the most inconvenient times. If you have a dental emergency that needs immediate attention, we will always offer to see you at once. We expect that other patients who might be slightly inconvenienced by this will be understanding of the situation. At some point, they may need the same courtesy too!

Like many offices, this office does call to confirm your appointment. Please make a note of any dental appointments we have scheduled in a place where you will be easily reminded. If you cannot make an appointment as scheduled, please notify the office.

There will be a charge of $45 per 30 minutes of scheduled time for a broken appointment or cancellation with less than 24 hours' notice for your appointment.

This fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred with out the payment of this fee. Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $45.00 cancellation fee will be charged.

If you have any questions about our appointment cancellation and no-show policy, please feel free to ask us.

 

General Dentistry Informed Consent Form

Dentist Name: Dr. William Harris

Work to Be Done - I understand that the following work may be performed:

• Fillings
• Crowns
• X-rays
• Extractions
• Impacted Teeth Removal
• Root Canal
• Dentures
• Periodontal Therapy
• Exams

Drugs and Medication - I understand that antibiotics, analgesics, and other medications may cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock. I have advised my dentist of any and all medciations I am currently taking, including but not limited to prescription medications, over-the-counter medications, herbal remedies, and alternative medications. I further understand that failure to advise my dentist of any medications I am taking prior to starting dental work may have unforeseen negative consequences for me.

CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change
or add procedures because of conditions found while working on the teeth that were not discoverable during
previous examinations. For example, root canal therapy may be necessary following routine restorative
procedures. I give my permission to my dentist to make any/all changes and additions as necessary.

REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy,
crowns, periodontal surgery, etc.), and I authorize the dentist to remove teeth that may cause impairment, damage, or illness.

I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved with extraction, some of which are pain, swelling, spread of infection, dry socket, and loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time, and fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my responsibility.

CROWNS, BRIDGES AND VENEERS: I understand that sometimes it is not possible to match the color of
natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which
may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are
delivered. I realize the final opportunity to make changes in my new crowns, bridge, or cap (including shape, fit, and color) will occur only before final cementation. It is also my responsibility to return for permanent
cementation within 21 days from initial tooth preparation. Excessive delays may allow for tooth movement
which may necessitate a remake of the crown, bridge, or cap. In such instances, I understand that there will be
additional charges for remakes due to my delaying permanent cementation.

ENDODONTIC TREATMENT (ROOT CANAL): I realize there is no guarantee that root canal
therapy will save my tooth, and that complications can occur from the treatment, and that occasionally root canal filling material may extend through the tooth which does not necessarily affect the success of the treatment. I understand that endodontic files are very fine instruments and stresses from their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoetomy). I understand that the tooth may be lost in spite of all efforts to save it.

PERIODONTAL THERAPY (TISSUE AND BONE): I understand that if I am being treated with periodontal therapy, this means I have a serious condition, causing gum and bone inflammation and that it can ultimately lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that any dental procedure may have a future adverse effect on my periodontal condition.

FILLINGS: I understand that care must be taken when chewing on fillings especially during the first 24
hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that increased sensitivity is a common effect of a newly placed filling.

DENTURES: I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty
in eating are common problems associated with dentures. Immediate dentures (placement of denture immediately after extractions) may be painful. In addition, immediate dentures often require considerable adjusting and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delay of 30 days or more, there may be additional charges assessed against me.

I understand that dentistry is an inexact science and that therefore, reputable practitioners cannot properly
guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment(s) which I have requested and authorized.

I hereby authorize any of the doctors or dental assistants or auxiliaries to proceed with and perform the dental
restorations and treatments indicated above and as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosed circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I may be responsible for payment of the dental fees.