Emergency Contact Information Primary Insurance Information What is the main reason for your visit? Are you in any dental discomfort? Select yes if you have any of the following:
Food collection between teeth
Grinding or clenching teeth
Loose teeth or broken fillings
Sores or growths in mouth
Pain that wakes you up at night
Have you ever experienced an adverse reaction during or in conjuction with a medical or dental procedure?
Have you had any serious illnesses or operations?
Are you currently under physician care?
Have you ever had a blood transfusion?
Are you pregnant or do you think you may be?
Do you or have you ever taken bisphosphonate medications for osteoperosis, cancer, or multiple myeloma (such as Fosamax, Actonel, Boniva, Reclast, Aredia, or Zometa)?
Are you taking birth control?
Select yes if you have or have had the following:
Kidney disease or malfunction
Material allergies (latex, wool, metal, chemicals)
Pacemaker / heart surgery
Rapid weight gain or loss
Swelling of feet or ankles
Thyroid disease or malfunction
Are you allergic to any of the following?
List any medications you are currently taking, if any: I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice also contains a patient rights section describing your patient rights under the law. You have a right to review this notice before signing the consent. The terms of the notice may change, and if this should occur, you may receive a revised copy by contacting the office.
You have the right to restrict how protected health information about you is used or disclosed for treatment, payment or healthcare operations. We are not required to agree to this restriction, but if you do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for the treatment, payment or healthcare operations via telephone, mail, fax, electronic mail, and verbal communications. You have a right to revoke this consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in relation to you on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
1. Protected health information may be disclosed or used for treatment, payment or health care operations.
2. The practice has a Notice of Privacy Practices and the patient has the opportunity to review this notice.
3. The practice reserves the right to change the notice of privacy practices.
4. The patient has the right to request restricted use of their information, but the practice does not have to agree to those restrictions.
5. The patient may revoke this consent in writing at any time and all future disclosures will then cease.
Thank you for selecting South Coast Metro Center for Dentistry & Implants as your dental care provider. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
For patients without dental insurance, full payment is required at time of treatment unless we have authorized a different payment plan. For patients with dental insurance we will work with our carrier to maximize your benefits and directly bill them for reimbursement for your treatment. Not all services are covered benefits by your insurances.
Your insurance policy is a contract between you and the insurance company. Our financial relationship is with you and not the insurance company. All charges are your responsibility whether your insurance company pays or not. All of the information we provide regarding your insurance benefits are only estimates.
Fees for services, including deductibles, co-payments, and services and procedures not covered or denied under your insurance plan are due at the time of treatment. If the insurance company does not pay your covered benefits within 30 days, we will ask that you contact the insurance carrier to expedite the payment process
If the insurance company does not pay your balance within 45 days, we will require that you pay the balance due. Balances older than 90 days are considered to be in delinquency and will be reported to the credit bureau and sent to collections. All fees associated with collection on your account will be your responsibility, including but not limited to collection agency fees in addition to the balance owed. A monthly 1.5% interest fee will be charged on account balances over 90 days.
Our office offers the following payment options:
• Cash, Check, Visa, Mastercard, American Express
• Payment Plans from CareCredit and Lending Club
Please note: We request 24 hour prior notice of any cancellations otherwise a $50 cancellation fee will be charged. Our office charges $30 for returned checks. If you have any questions, please do not hesitate to ask. 1. Work to be done: As a new patient, I understand that I am having an exam and x-rays taken.
2. Drugs and medications: 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 medications 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. 3. Photo authorization: I consent to photography, filming, recording, and x-rays of my oral structures as related to my dental procedures and for their educational use, provided that my identity is not revealed.
4. 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. Submit