Everhart Dental Family & Cosmetic Dentistry

Patient Information

Patient Name: _______________________________________________________ Date: _________ Last First MI (Preferred Name)

Address: ______________________________________________________________________________ Street City/State Zip code

Gender: (M or F) ____ Marital Status: Single Married Divorced Widowed DOB: _____________

Whom may we thank for referring you? ________________________ Email _____________________________

Phone (Home) ________________ Phone (Work): _____________Ext: ____ Cell # _________________

Best time to call ______________ SS#: _______________________ Occupation: ____________________

Emergency Contact: Name_______________________ Address_________________________ Tele#______________

Insurance Information

Subscriber Name ___________________________ SS#/ID#____________________ DOB ___________

Insurance Co. ______________________________ Group Number _____________ Phone ____________

Mailing Address _________________________________________ Employer ______________________

Effective Date _____________ Coverage: Individual ____ Spouse ____ Children ____

Health Information

Physician’s Name___________________________ Address_____________________________________

Telephone # _____________________ Date of Last Physical ____________________________________

List Any Known Drug Allergies or Other Allergies? ___________________________________________

Have you ever had any of the following? Please check those that apply: ____ Anaphylactic Shock ____ Epilepsy ____ HIV Positive/AIDS ____ Pregnant (currently)

____ Anemia ____ Glaucoma ____ Kidney Disease ____ Penicillin Allergy

____ Taking Aspirin ____ Heart Attack ____ Liver Disease ____ Respiratory Problems

____ Artificial Joints ____ Heart Disease ____ Mental Disorders ____ Rheumatic Fever

____ Arthritis ____ Heart Murmur ____ Mitral Valve Prolapse ____ Sinus Problems

____ Cancer ____ Hepatitis ____ Nervous Disorders ____ Sexually Transmitted Disease

____ Diabetes ____ High Blood Pressure ____ Pace Maker ____ Tuberculosis

Do you need to pre-medicate before your appointments? ________ Are you currently taking any over-the-

counter or prescription medication? _______ If so, please list them ______________________________________

Everhart Dental Family & Cosmetic Dentistry

Patient Information

What is the reason for this visit? ___________________________________________________________

How long since your last dental visit? ______________________________________________________

Previous dentist’s name and address: _______________________________________________________

When were X-rays last taken of your teeth? __________________________________________________

How frequently do you brush your teeth? ____________________________________________________

Do you use a soft or hard bristle toothbrush? __________________________________________________

Yes No Do you clench or grind your teeth?

Yes No Do you have any tooth, jaw, or muscle discomfort?

Yes No Do you have a click, pop, or other noise in the jaw joint?

Yes No Are your teeth sensitive to hot or cold?

Yes No Are any of your teeth uncomfortable to bite on?

Yes No Do your gums bleed when brushing or flossing your teeth?

Yes No Would you like information on whitening your teeth?

Yes No Are you interested in cosmetic bonding or straightening your teeth?

_____________________________________________________________________________________ I hereby authorize and consent to Sandra Pojtek, D.M.D. to perform any dental procedures deemed necessary for me, my minor children and family members and to release any information, including the diagnosis and records of any treatments, x rays, photographs, or examinations rendered, to my insurance company (if applicable). I hereby authorize my insurance company to pay directly to Sandra Pojtek, D.M.D., Family & Cosmetic Dentistry, any proceeds payable under the terms of my insurance policy.

I consent and agree to Sandra Pojtek, D.M.D. to be financially responsible for payment of any outstanding balance (that is not fully covered by insurance, if applicable) for all services rendered to me and my family members.

I will inform Sandra Pojtek, D.M.D. of any changes in my health and I have read and understand the HIPAA Privacy Form provided for me.

I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I hereby certify that I have read and understand all of the preceding information and that it is accurate and true to the best of my knowledge.

___________________________________________________________________ ________________ Signature of Patient or Guardian (Relationship to Pt.) / Print Name Date

Everhart Dental Financial Policy (for all patients) Thank you for choosing us as your dental care provider. The following describes our Financial Policy. Our office is committed to providing you with the best possible care. Your understanding of our financial policy is an essential element of your care and service. If you have any questions regarding any aspect of our policy, please feel free to ask us. Payment for services is due at the time services are rendered unless a payment arrangement is agreed upon ahead of time. We accept cash, debit, Visa, MasterCard, American Express, Discover and third party financing through Care Credit. Our patients who have dental insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service. Payment in advance may be required for certain treatment in order to reserve chair time and fund dental laboratory fees. Deposit Policy: Due to the extensive amount of time our staff and doctor devote to preparing and reserving uninterrupted time for certain appointments/specific treatment, we require a deposit to make your reservation. ________initials Appointment Policy: We work hard to accommodate appointments that fit your schedule and dental needs. We ask that you let us know about changes at least 24 hours in advance. We do understand that life happens, but any missed appointment without the 24 hour call may be subject to a $50 short/no notice fee. A confirmed appointment is a promised appointment. If you fail to confirm your appointment in a timely manner, we reserve the right to offer your spot to another patient. Habitual missed appointments are grounds for dismissal from the practice. ________initials I have read and understand the Financial Policy and Appointment Policy for Everhart Dental. I agree to abide by these policies. Patient/Guardian Signature: ____________________ Printed Name: ____________________ Date: ____________________ Insurance Policy and Assignment of Benefits (for patients with dental insurance only) As a courtesy, we will educate you and file the forms necessary to see that you receive the full benefits of your coverage. Because your insurance policy is a contract between you, your employer, and the insurance company, it is your responsibility to make sure we have accurate and up to date insurance carrier information, restrictions of your policy, and billing information. Please understand that the treatment plan provided is an estimate of what your insurance may cover and can differ once claims are submitted. Please be aware some of the services provided may not be covered by your insurance provider. Services which are not covered, partially

covered, or downgraded may leave you with a balance that is your responsibility. We will send you a statement in the mail and any balance left unpaid after 30 days will be sent to collections. In the same vein, a refund check or credit to you will be issued if insurance has paid more than what was estimated in your treatment plan. ________initials I hereby authorize my primary and/or secondary insurance company to make payments directly to Everhart Dental. Furthermore, I have read and understand the Insurance Policy for Everhart Dental. I agree to abide by these policies. Patient/Guardian Signature: ________________________ Printed Name: ________________________ Date: ________________________