• New Patient Packet

    Heinle Dental

  • Welcome!

    Welcome to Heinle Dental, the office of Dr. Ronald Heinle. We're honored that you've chosen us as your dental home.


    Our Mission
    At Heinle Dental we provide exceptional dental care based on each patient's individual needs. We offer our patients the most advanced and comprehensive dental care available. Our top priority is to help you achieve and maintain a beautiful, healthy smile. We understand each patient has different needs and desires, and we promise to work with you individually to create a personalized treatment plan that will deliver optimum results!


    Our Doctor
    Dr. Heinle is highly skilled in providing comprehensive dental care for patients of all ages. He went into partnership with his childhood dentist directly after graduating from Georgetown University Dental School in 1987. Dr. Heinle participates in extensive continuing education each year to ensure he delivers the best possible care to our patients.


    Our Experience
    The entire team at Heinle Dental is trained to provide exceptional care and treat each patient as an individual. Our team members bring years of dental training and experience together to ensure your oral health needs are met.

    Our Expertise
    We offer a range of comprehensive dental services to meet all of your dental health needs. Please review the Menu of Services provided in this packet, and ask any member of our team for more information about what we can do for you!


    Our Commitment
    We understand the importance of affordable dental care and are committed to working with you to ensure that you get the care that you need. Our Office Manager will work with you personally to verify any insurance benefits available to you. We also offer a variety of convenient payment options including cash, check, credit card, and in-office financing for approved accounts.


    740 Pittsford Victor Road

    Pittsford, NY 14534

    585.248.2824 P

    585.248.2665 F

    www.heinledental.com

     

  • Your Future Appointments

    Personalized Dental Care for Your Unique Needs

    We look forward to seeing you again!


    As schedules overflow with personal responsibilities, activities and other commitments, we understand the juggling act you are balancing. We are dedicated to helping you ensure that your dental health continues to be a priority so that you can enjoy the benefits of a healthy smile for years to come.


    Your dental appointments are scheduled to ensure that you receive the treatment and preventive services that you need in a timely manner. Dr. Heinle and your dental hygienist or dental assistant will discuss with you the appropriate timing of any dental treatment and the interval of hygiene re-care appointments that is best for you. Our goal is always to keep you healthy and avoid the cost and inconvenience and pain of dental emergencies.


    As a service to you, we will send you an email several days before your scheduled appointment. İf you have provided us with your cell phone number, you will also receive a text message regarding your appointment. At any time, you have the flexibility to customize the types of communication that you receive from us.


    Appointment time is reserved for you based on your specific needs. If you must make a change to a scheduled appointment, we ask that you notify us at least 24 hours in advance. This allows us to offer ths appointment tme to another patient waiting for an opening in our schedule. In addition, if you have experienced any change in your condition or your medical history, please call us ahead of time so that we may determine any impact to your appointment.

    We look forward to caring for you for many years to come!

  • It's Not Just a Cleaning!

    Prevention should serve as a lifestyle pattern for total health, not the least of which is dental health. Prevention in dentistry leads to improved long-term oral health and reduced dental costs. It encourages a bright smile, fresh breath, and an overall good feeling of personal security. Prevention is your insurance policy toward a healthier, pain-free, happier lifestyle.


    Our hygienists provide excellent service to assist in the maintenance of your overall dental health. Your cooperation can serve to increase your knowledge of your present oral condition. When you keep your regularly scheduled appointments with your hygienist, the following benefits will result:

    • Our hygienist will customize a personal home and periodontal maintenance program for you, and inform you of those dental products which are appropriate for your particular needs. You will be instructed in the proper methods of toothbrushing, flossing, and adjunctive dental health devices.
    • Your entire mouth will be thoroughly and carefully examined for periodontal (gum) disease, growths, lesions, and any abnormalities that would affect your general health.
    • Your teeth will be scaled, root planed, and polished to remove plaque and calculus (tartar) both above and below the gum line, eliminating bacteria that lead to cavities, bad breath, and gum disease.

    Periodontal disease is a silent invader, presenting itself in various forms such as puffy, bleeding gums. Although your mouth may appear to be in good health at this time, stresses, body changes, life changes, medications, illness, and age can tax your immune system. Maintaining regular re-care appointments with your hygienist and follow-ups with your dentist and periodontist offers you the assurance that any problems in regard to your oral care will be addressed immediately.


    Taking care of tomorrow's problems today will give you tremendous peace of mind.


    Remember: it's not just a cleaning, it's an INVESTMENT in your overall health!

  • Implants

     

    What is a Dental Implant?

    A dental implant is surgically inserted in the mouth to replace one or more missing teeth. The implant has three components:

    • Titanium anchor – surgically inserted into the jawbone
    • Abutment – protruding post attached to the anchor
    • Crown – man-made porcelain crown (replacement tooth) mounted on the abutment

    How will I benefit from a dental implant?

    Benefits include an improved smile and appearance, the enhanced ability to chew and enjoy food, and protection of the other teeth and jawbone. In addition, an implant...

    • Becomes a permanent part of the mouth, integrated into the surrounding bone
    • Doesn't slip, move, or irritate gum tissue, unlike dentures
    • Minimizes jawbone degeneration from missing teeth

    Is the implant procedure painful?

    Implant surgery requires the use of local or general anesthesia to minimize discomfort. After implant surgery, patients may experience some swelling and/or tenderness. Dr. Heinle may prescribe pain medicine depending on the patient's condition. After the procedure, patients will usually be advised to eat soft foods for up to a week.

    How much does an implant cost?

    The fee varies according to the number of implants and the complexity of the procedure. Dental implant treatment usually takes longer and costs more than other replacement options. However, implants are considered the best tooth replacement option, more long-lasting and function more like natural teeth.

    How long will treatment take?

    It varies according to the needs of the patient and the extent of the procedure. Typically, treatment takes from three to nine months.

    If you have other questions, any team member will be delighted to answer them.

  • New Patient Information

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Best place to reach you during the day:

  • New Patient Information (Continued)

  • X-Rays:

  • Do you have dental insurance?
  • Policy Holder's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Our Insurance Claim/Reimbursement Policy Explained

  • 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.
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you under a physician's care now?*
  • Have you ever been hospitalized or had a major operation?*
  • Have you ever had a serious head or neck injury?*
  • Are you taking any medications, pills, or drugs?*
  • Do you take, or have you taken, Phen-Fen or Redux?*
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*
  • Are you on a special diet?*
  • Do you use tobacco?*
  • Do you use controlled substances?*
  • Questions for Women: Are you...
  • Are you allergic to any of the following?
  • Do you have, or have you had, any of the following? (Part 1/4)
    Rows
  • Do you have, or have you had, any of the following? (Part 2/4)
    Rows
  • Do you have, or have you had, any of the following? (Part 3/4)
    Rows
  • Do you have, or have you had, any of the following? (Part 4/4)
    Rows
  • Have you ever had any serious illness not listed above?*

  • 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. 

  • Patient Registration

  • Patient Is:

  • Responsible Party (if someone other than the patient)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Responsible party is:

  • Patient Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Sex
  • Marital Status
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • I would like to receive correspondence via email

  • Patient Information - Section 2

  • Employment Status
  • Student Status

  • Patient Information - Section 3

  • Format: (000) 000-0000.

  • Primary Insurance Information

  • Relationship to Insured:
  • Insured's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Employer Information

  • Insurance Information

  • Secondary Insurance Information

  • Relationship to Insured:
  • Insured's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Employer Information

  • Insurance Information

  • Smile Assessment

  • See if you might be a candidate for an enhanced smile:

  • Answer the following questions:
    Rows
  • What is holding you back from your perfect smile?
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • If you are a new patient:

  • What was the date of your last dental exam?:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • I,       , have received a copy of Heinle Dental's Notice of Privacy Practices -OR- I have read a copy of this notice at www.heinledental.com.

  • **You May Refuse to Sign This Acknowledgement**
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Financial Policy

  • Thank you for choosing HEINLE DENTAL for all your dental needs.
    Below is our Financial Policy - please take a moment to review and sign for our records.
    • Payment for all services rendered is expected at time of service
    • For your convenience, payment plans for extensive treatment are available, subject to approval
    • Other payment plans may be arranged per patient circumstance, subject to approval
    • A monthly finance charge of 5% will be added to any overdue balance
    • Accounts 90 days past due will be referred to a Collection Agency and all Collection Agency fees and charges will be added to any oustanding balance
    • We will electronically submit your dental insurance claim and reimbursement will be made to you directly
    • We accept personal checks, cash, Visa, MasterCard and Discover
    • We require a minimum of 24 hours notice (business days excluding weekends) for all appointment changes/cancellations to avoid a "no-show" fee.
  • I hereby certify that I have read, understand and agree to the above financial policy:
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: