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Microsoft word - let's smile new patient pedo paperwork july 2012

Whom may we thank for referring your child to our office I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform Fairfax Corner Orthondontics and Pediatric Dentistry of any changes to the information I have provided. I agree to be responsible for all charges for dental services and materials not paid by my dental plan benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or portion of such charges. To the extent permitted by law, I authorize release of any information relating to claims filed. I hereby authorize payment of the dental benefits otherwise payable to me directly to Let’s Smile Pediatric Dentistry and Orthodontics. Let’s Smile! Pediatric Dentistry and Orthodontics Please list any medications your child is currently taking: Does your child have, or has he/she ever had, any of the following diseases, conditions or procedures? □ Convulsions, Seizures, Fainting or Epilepsy □ Rheumatic Fever/ Rheumatic Heart Disease □ Congenital Heart Disease or Heart Murmur □ Speech, Learning, or Hearing Disorders □ Diabetes/Blood Sugar Problems □ Glandular or Hormonal Problems □ Any Recent or Pending Surg./Recent injuries □ Liver Problems, Jaundice or Hepatitis Are your child’s immunizations current? Does your child need a cleaning prior to dental work? t : □ Latex □ Penicillin/Amoxicillin □ Tetracycline □ Red Dyes □ Aspirin □ Sulfa Drugs □ Dental Anesthetics □ Other(s) t ? □ Thumb Sucking □ Mouth Breathing □ Pacifier □ Nail Biting □ Finger Sucking □ Grinding/Clenching □ Other(s) Do you have any current records (including x-rays) from another practice? Has your child ever complained about any dental problems? Does your child still take a bottle or sippy cup? Does your child brush daily? □Yes □No How Often? Do you assist your child with brushing? □Yes □No How Often? □ Water Supply □ Dentist □ Toothpaste □ Vitamins □ Tablets □ None □ Other Reason for Today’s Visit/Chief Concerns: I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. Let’s Smile! Pediatric Dentistry and Orthodontics As a condition of your treatment by Let’s Smile! Pediatric Dentistry & Orthodontics (herein referred to “Let’s Smile” or “Office”), financial arrangements must be made in advance. Let’s Smile depends upon reimbursement from its patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are preformed. Patients who carry dental insurance understand that all dental services provided are charged directly to the patient and that he/she is personally responsible for payment of all dental services. Let’s Smile will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. However, the Office can and will not render services on the assumption that our charges will be paid by an I understand that Let’s Smile gives me a treatment plan based on my insurance company’s estimates. This estimate is not a guaranteed payment; the insurance company is unable to provide the exact amount that will be paid until they receive the claim. Let’s Smile presents the best treatment plan based on the percentage of coverage provided by my insurance company. I understand that the fee estimate listed for this dental care can only be extended for a period of six (6) months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or her assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition, and I agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to Let’s Smile or Office’s assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and payment and agree to their Signature of Patient, Parent or Guardian Let’s Smile! Pediatric Dentistry and Orthodontics 1. Charges of services rendered are due and payable the day of appointment. 2. Let’s Smile assist with filing insurance; however, the Patient, Parent, or Guardian is directly responsible for payment in full of any and all fees not paid for by the insurance company. Th o s. When treatment co-pays are quoted by the office, these are estimates only, your actual insurance coverage may be less or more. 3. Personal checks that are returned due to insufficient funds are subject to a $30.00 service fee. 4. Appointment cancellations with less than 48 hour’s notice are subject to a fee of $50.00 for appointments scheduled for less than two (2) hours and $200.00 for appointments scheduled for 5. All accounts over 60 days are considered past due. Such accounts are subject ot 18% APR or 1.5% monthly finance charges. Past due accounts may be referred to an authorized collection agency. Accounts sent to a collection agency will be assessed a $30 collection fee or 33 1/3% collection charge on the unpaid balance, whichever is greater. The Patient, Parent, or Guardian will also be liable for any applicable attorney fees and court costs. Accounts that have been referred to an outside collection agency will be placed on a CASH ONLY basis for any future treatment. 6. We are required by the State of Virginia to keep patient records for three years past the final date of treatment. Records of patients that have not been to this office in over three years may be purged. If you are moving or leaving the practice for any reason you may want to request a copy for your records. There may be a minimal charge to copy your x-rays and records. 7. Payment plans are available only for orthodontic treatment. 8. Amalgams (silver fillings) are not provided at this office. Most insurance companies do not pay full benefits due to exclusions in individual policies for composite (tooth colored) fillings. The Patient, Parent or Guardian is liable for all additional costs. I have read and understand the Financial Policy of Fairfax Corner Orthodontics & Pediatric Dentistry. I agree to be responsible for all services and materials not paid by my dental insurance for me and my dependents. I authorize release of any information relating to any insurance claims to the relevant insurance company. I authorize payment of dental insurance benefits to Fairfax Corner Orthodontics & Pediatric Dentistry, unless payable to me directly per the Insurance Plan. Signature of Patient, Parent or Guardian Let’s Smile! Pediatric Dentistry and Orthodontics Fairfax Corner Orthodontics & Pediatric Dentistry , have received a copy of this office’s We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Let’s Smile! Pediatric Dentistry and Orthodontics From time to time our practice features patients in clinical presentations, new patient consultations and for advertising/marketing purposes. By signing this release, I hereby give Let’s Smile Pediatric Dentistry and Orthodontics and all persons and companies acting with their authority permission to copyright, use, re-use, publish, and/or re- publish, any and all photographic portraits, pictures and/or videographic pictures or recordings of me and/or my minor child(ren) listed below, or audio recordings of my voice or the voice(s) of my minor child(ren) listed below, or in which I am (or they are) included, without restriction. I also consent to the use of printed matter in conjunction Let’s Smile! Pediatric Dentistry and Orthodontics Fairfax Corner Orthodontics & Pediatric Dentistry



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