Patient Intake Forms - Diamond Dental of Owings Mills

Patient Intake Form
WELCOME...We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. Our team is here to provide top-notch care for all your oral health needs. We're excited to help you achieve your best smile.
Patient Name

First NameMiddle NameLast NameSuffix
Social Security Number
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Email
example@example.com
Sex
Marital Status
How did you hear about our office?

Release of Information

HIPAA Consent
Notice of Privacy Practices
I have been provided the opportunity to review the Notice of Privacy Practices prior to signing this consent. Diamond Dental of Owings Mills and its affiliates reserve the right to revise the Notice of Privacy Practices at any time. In compliance with the Federal Health Insurance Portability and Accountability Act, “HIPAA” With your written permission, we will not share your information with anyone other than your insurance carrier, pharmacist, physician or other dental specialist.

I hereby give my consent for Diamond Dental of Owings Mills to disclose protected health information (“PHI” including appointment reminders, treatment options and finances) about me or my minor dependents to the following trusted persons in conformance with Diamond Dental of Owings Mills Notice of Privacy Practices. I understand that I may revoke this permission at anytime by submitting a written request to Diamond Dental of Owings Mills.
I hereby give my consent for Diamond Dental of Owings Mills to disclose protected health information to the following individuals:

Self Only
Name, Relationship, Phone number (add new line for each)
Signature

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Date

MonthDayYear

Office Policies
Payment for dental services are due at the time of service.

For your convenience, we accept cash, Visa, MasterCard, Discover and Care Credit (third party financing). Diamond Dental of Owings Mills is not a lending institution; therefore, we cannot offer in house payment plans. In partnership with Care Credit we offer deferred interest for up to 12 months on Care Credit transactions over $300. We offer the Dental Savings Plan and annual membership that offers our best discounts to those without dental insurance.

Dental Insurance Policy: Please be prepared to pay a percentage of your visit along with your deductible on the date services are rendered. Diamond Dental of Owings Mills and Monica Mattson, D.D.S. are not contracted providers for any insurance plan. As a courtesy to our patients, we do submit claims to PPO dental plans. Unfortunately, we can not submit claims on HMO or state funded policies. Once your insurance has paid its allowable amount, you are responsible for any remaining balance. Doctor Mattson is an unrestricted provider, allowing her to provide the highest standard of care. Our staff will work with you to maximize your dental benefits. We recommend that you personally review your specific dental insurance benefits, as all policies differ. We will do our best to accurately estimate your copay prior to treatment, however, all dental insurance plans have unique restrictions that may be unforeseen. You are ultimately responsible for the full office fee for any treatment provided at Diamond Dental of Owings Mills. Our office does not guarantee any estimates and we take no responsibility for any denials by the insurance company. Some insurance companies reimburse the policy holder directly.

** Blue Cross/ Blue Shield (CareFirst) and select Delta Dental Plan holders** Your insurance company has stated that they will only send payment for covered services directly to you. Due to this policy, we ask that you pay for all dental services in full on the day of your appointment. Diamond Dental of Owings Mills will file your insurance claim for you. However, all correspondence from the insurance company will then only be communicated to you. Please, let us know if there are any problems with the claim. We will cooperate fully with the regulations and requests of your insurance company until your payment has been finalized. Generally, insurance claims are settled within 30 days, contact our office if you have not received reimbursment within this time frame.

Billing Policy - In the event of a remaining balance, we will send a statement via the USPS followed by text message reminders with a link to your invoice. Please note that if you opt - out (STOP) of text messages from 443-394-2273, you will not receive these digital statements or any appointment reminders. Payments can also be made at diamonddentalofowingsmills.com.

Any outstanding balances older than 30 days will be subject to interest charges of 1.5% per month. After 90 days, unpaid accounts will receive a final notice via USPS before they account is referred to a third-party collections agency. The patient shall be responsible for the unpaid balance plus the reasonable cost of a collection agency (35% of balance due), attorney, and/or court costs. The undersigned hereby waives any defense he/she may have as to the statute of limitations barring future attempts to recover debts owed hereunder in the event of default.

Returned checks will be subject to a $35.00 check fee, in addition to any bank fees associated with the transaction.

Cancellation Policy - At Diamond Dental of Owings Mills, we strive to provide quality care in a timely manner for all patients. We commit to being respectful of your time by scheduling appointments that allow our providers ample time to provide quality individualized care. Likewise, we ask you to prioritize your dental appointments and consider our staff who prepare in advance for your visit. Please call OR text our office as early as possible if you need to reschedule. This helps our office to continue to provide superior care in a timely manner for all of our patients. Any appointment that is missed or cancelled with less than one business day (24 hours) of notice will be subject to a $50 fee.

I understand and agree to Diamond Dental of Owings Mills office policies.
Signature

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Date

MonthDayYear
Date

Dental Insurance

Primary
Please provide a copy of your dental insurance card to our staff. If you do not have a physical card please text a picture of the front and back of the card to 443-394-2273.

If you do not have dental insurance please skip this section.
Primary Dental Insurance Company
Member ID
Subscriber's Name
Social Security Number (Primary Subscriber)
Date of birth (Primary Subscriber)

MonthDayYear
Phone Number (Primary Subscriber)
Relationship to Patient
Primary Subscribers Employer
Specify individual policy, if plan is not through employer
Are you covered under any other dental insurance Policies?

YesNoYes, my medical insurance has dental benefits
Dental Insurance

Secondary
Secondary Dental Insurance
Member ID
Subscriber's Name
Social Security Number (Policy Holder)
Date of birth (Policy Holder)

MonthDayYear
Phone Number (Policy Holder)
Relationship to Patient
Policy Holders Employer
Specify individual policy, if plan is not through employer

	Detailed explanation
What is the reason for your Dental visit today?
Date of your last dental cleaning?
Have you ever had a "deep" cleaning? If so when?
Date of your last dental x-rays?
Are you currently experiencing dental pain or discomfort?
Are your teeth sensitive to hot, cold, sweets or pressure?
How do you feel about your smile?

	Yes	No	Details (upper, lower, left, right, etc.)
Do your gums bleed when you brush or floss?
Does your floss ever catch between your teeth?
Have you had Periodontal (gum) treatment in the past?
Is your mouth dry?
Have you ever had orthodontic (braces) treatment?
Have you had problems associated with previous dental treatment?
Is your home water supply fluorinated?
Do you have earaches or neck pain?
Do you have clicking, popping or discomfort in the jaw?
Do you grind your teeth?
Do you have a night guard?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Have you ever had a serious injury to your head or mouth?

	Yes	No	Details
Are you currently taking any blood thinner medication?
Has a physician ever recommended that you take antibiotics before a dental treatment?
Do you have congenital heart disease (CHD) that is: Unrepaired, cyanotic CHD; Repaired (completely) in the last 6 months OR Repaired CHD with residual defects?
Damage to valves in a transplanted heart?
Do you have an artificial heart valve?
Previously infective endocarditis?
Have you ever had a total joint replacement? If so, when and did you have any complications?
Since 2001, were you treated or are you presently scheduled to begin treatment with intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer? Dates of treatment?
Are you taking or scheduled to begin taking either of the medications, Fosamax (alendronate) or Actonel (risedronate) for Osteoporosis or Paget's disease?
Do you have any other medical condition, disease or problems you would like us to know about?
Do you use tobacco products? (vape, smoke, snuff, chew etc.) *indicate frequency
Do you drink alcoholic beverages? *Indicate frequency
Do you use drugs or controlled substances not prescribed to you? *Indicate frequency
Do you use marijuana? (vape, smoke, edibles, etc.) *Indicate frequency

	Yes	No	Details
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sleeping bills or sedatives
Sulfa Drugs
Codeine or other narcotic medications
Metals
Latex
Iodine
Seasonal/ Hay Fever
Animals
Food
Other

	Yes	No	Details
Are you currently pregnant? *indicate due date
Are you currently nursing?
Do you take birth control pills?
Do you take any hormone replacements?

Patient Intake Form

Release of Information

Office Policies

Dental Insurance

Dental Insurance

Health History

Health History