[NORMAL] PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION

Last Name: ___________________________________ First: _____________________________ MI: _________ Preferred Name: _______________________________________ SS#: ________________________________ DOB: ___________________________ Marital Status: S / M / D / W Sex: M / F

Home Address: _____________________________________ City/St/Zip: _____________________________ Home Phone: _____________________ Cell: ___________________ Work number: ___________________ E-mail Address: ______________________________________________________________________________ Employer Name & Address: __________________________________________________________________

Emergency Contact: ______________________________________ Phone

: _____________________

Primary Health Care Physician: _____________________________ Phone: __________________________ Responsible Party for Patient: (please print) ___________________________________________________ Statement Mailing Address (if different): _______________________________________________________ Please take a moment to tell us how you heard about our office.

Newspaper/Internet/Yellow Pages/Billboard/Other_______________________________________________________ Family or Friend________________________________________________________________________________________

INSURANCE INFORMATION

Subscriber Name & Address: _________________________________________________________________ Subscriber SS#: ___________________ DOB: ________________ Relation to Patient: _________________ Employer Name & Address: __________________________________________________________________ Insurance Company Name & Address: _______________________________________________________ Group #: ____________________________ Insurance Phone: _____________________________________ SECONDARY INSURANCE

Subscriber Name & Address: _________________________________________________________________ Subscriber SS#: ___________________ DOB: ________________ Relation to Patient: _________________ Employer Name & Address: __________________________________________________________________ Insurance Company Name & Address: _______________________________________________________ Group #: ____________________________ Insurance Phone: _____________________________________

Insurance Assignment and Disclaimer

I assign directly to Dr. Brammer, Dr. Jourdan and Dr. Turney all benefits, if any, otherwise payable to me for services rendered. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

I understand that my insurance coverage is between my insurance carrier and me. I understand as a benefit to me, Main Street Dental Associates, will assist me in estimating my insurance benefits as well as filing claims on my behalf. All estimations for insurance benefits are NOT final and are by definition, an estimate. I understand that I am responsible for all fees regardless of insurance coverage.

FINANCIAL AGREEMENT

I acknowledge that payment is due at the time of treatment unless other arrangements are

made. I agree that parents/guardians are responsible for all fees and services rendered for

treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance.

Signature______________________________________ Date _______________________

MINOR/CHILD CONSENT

I, being the parent or guardian of _________________________ do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.

Signature______________________________________ Date _______________________

MEDICAL INFORMATION

WOMEN ONLY

Are you pregnant? Yes / No How many weeks? ______ Breastfeeding?

______

Check any of the following that you have had or suspect that you have had:

____ Arthritis ____ Hepatitis or Jaundice ____ Abnormal Bleeding

____ Rheumatic Fever ____ Liver Disease ____ Fainting Spells

____ Heart Trouble ____ Cancer or Tumor ____ Seizures

____ Heart Murmur ____ Tuberculosis ____ Thyroid Disease

____ Mitral Valve Prolapse ____ Diabetes ____ Glaucoma

____ High/Low Blood Pressure ____Kidney/Bladder Trouble ____ Radiation Treatment

____ Stroke ____ Anemia ____ Mental Disorders

____ Difficulty Breathing ____ Lung Disease ____ HIV or AIDS

____ Asthma ____ Venereal Disease ____ Joint Replacement

____ Sinus Trouble ____ Blood Disorder ____ Frequent Headaches

Do you smoke? Yes _____ No _____

Have you been in the hospital or had a serious illness in the last 5 years? Yes / No

Explain: ______________________________________________________________________

Are you now or have you recently been under a physician’s care? Yes / No

Reason: _____________________________________________________________________

Have you ever taken any of the group of drugs referred to as “fen-phen”? These

include combinations of Adipex/Ionimin/Fastin/Pondimin/Redux. Yes / No

Check any of the following that you are taking or have taken:

____ Cortisone Drugs ____ Anticoagulants ____ Tranquilizers

____ Steroids ____Blood Thinners ____ Sedatives

____ Birth control pills, shots, or implants ____ Hormone replacement therapy

Are you taking any other medications? Yes / No List:

_________________________

______________________________________________________________________________

Check any of the following that you are allergic to or suffer ill effects from:

____ Penicillin ____ Codeine ____ Dental Anesthesia

____ Aspirin ____ Household bleach ____ Sulfa

____ Other: _________________________________________________________________________________

The above information is true to the best of my knowledge.

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act. Of 1996

(“HIPAA”), I have certain rights to privacy regarding my protected health information. I

understand that this information can and will be used to:

1 Conduct, plan and direct my treatment and follow-up among the multiple

healthcare providers who may be involved in that treatment directly and indirectly.

2 Obtain payment from third-party payers.

3 Conduct normal healthcare operations such as quality assessments and physician

certifications.

I acknowledge that I may receive a copy of your Notice of Privacy Practices containing a

more complete description of the uses and disclosures of my health information. I

understand that this organization has the right to change its Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is

used or disclosed to carry out treatment, payment or health care operations. I also

understand you are not required to agree to my requested restrictions, but if you do agree

that you are bound to abide by such restrictions.

Patient Name: __________________________________

Relationship to Patient: __________________________________

Signature: __________________________________

Date: __________________________________

Please list below any person that you authorize to have access to the patients’ medical

information.

Name: ____________________________ Relationship: ____________________

Name: ____________________________ Relationship: ____________________

Name: ____________________________ Relationship: ____________________

Name: ____________________________ Relationship: ____________________

Main Street Dental Associates

1306 N Main Street

Miami, OK 74354

(918) 542-2858

Insurance Policy and Financial Policy

At Main Street Dental Associates, we believe that you deserve the best care. That’s why we always present you with the best dental solution possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental benefits but some don’t. If you have dental benefits, congratulations! You are very fortunate. Here are some important things you should know.

Initial

_______Your dental benefits are based upon a contract made between your employer and your insurance company. If you have any questions regarding your dental

benefits please contact your employer or insurance company directly. Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you.

_______We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or require our office to accept a reduced

fee for service). This means that we work with literally thousands of companies. Although we can maintain computerized histories of payment by a given company, they do change; therefore it is

impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment. Keep in mind this is not a guarantee of coverage. This does delay treatment but will give you the exact out of pocket figures you may require.

_______We will bill your insurance as a courtesy. If insurance does not pay within 90 days, Main Street Dental Associates will request immediate payment in full for

services from you and let you collect the insurance funds that are due to you. This is rare but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

_______We offer a 5% courtesy accounting adjustment to patients who have no insurance and pay for their treatment with cash or check prior to initiation of

treatment. There is no exception to the 5% adjustment. Fees must be paid before treatment begins. This does not include hygiene, i.e.- exams, cleanings, x-rays.

_______ Main Street Dental Associates does require payment in full for your portion at the time of service. We accept MasterCard, Visa, American Express, Discover,

cash and checks. If you are in need of an extended finance option, we also work with Care Credit who offers 3, 6, or 12 months “same as cash” or longer terms with an interest bearing revolving charge designed to meet your treatment plan needs on approved credit.

_______A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your

appointment, we require at least 24 hour notice to avoid a $50/hour scheduled treatment time fee (emergencies are an exception).

I agree with the above conditions.

Print name: ___________________________________ Date: _______________________

Signature Patient/Guardian: __________________________________________________

Main Street Dental Associates

1306 N Main Street

Miami, OK 74354

(918) 542-2858

GENERAL DENTISTRY INFORMED CONSENT FOR TREATMENT WORK TO BE DONE

I understand that I may be having the following work done: Fillings_____, Crowns/Bridge_____, Extractions_____, Endodontic Therapy_____, Dentures_____, X-rays_____, Other _______________. (Initials__________)

DRUGS AND MEDICATIONS

I understand that antibiotics, analgesics and other medications can cause allergic reactions: redness, swelling, pain, itching, and/or anaphylactic shock.

(Initials__________)

LOCAL ANESTHESIA

Certain possible risks exist that, although rare, could include pain, swelling, bruising, infection, nerve damage (numbness) and unexpected allergic reactions which could result in heart attack, stroke, brain damage and/or death. (Initials__________)

CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination. For example, endodontic therapy following routine restorative procedures. I give my permission to Dr. Jourdan/Dr. Brammer/Dr. Turney to make any/all changes and additions necessary with my consent. . (Initials__________)

CROWNS/BRIDGES

I understand that sometimes it’s not possible to match the color of artificial teeth exactly to the natural teeth. I further understand that I may be wearing temporary crowns/bridges that may come off easily and that I must be careful to ensure that they are kept on until the permanent crown/bridge is delivered. I realize that the final opportunity to make changes to my restoration (including shape, size, fit and color) will be BEFORE permanent cementation. It is also my responsibility to return for permanent cementation within 21 days from the preparation date. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown or bridge. I understand there will be additional charges for remakes due to me delaying permanent cementation and/or changes made after the permanent restoration has

been placed. (Initials__________)

ENDODONTIC TREATMENT (Root Canal)

I realize there is no guarantee that root canal treatment will save my tooth, and complications can occur from the treatment, and that occasionally root canal filling materials may extend through the tooth, which does not necessarily affect the success of the treatment. I understand that endodontic files and reamers are very fine instruments: stresses vented in their manufacture can cause them to separate or break during use. I understand that sometimes additional surgical procedures may be necessary following root canal treatment (Apicoectomy). I understand that the tooth may be lost in spite of all the efforts to save it. Root canalled teeth must be covered by crowns or bridges. (With rare exceptions of front teeth.) (Initials__________)

PERIODONTAL LOSS (TISSUE AND BONE)

I understand that if I have a serious condition causing gum inflammation, bone loss and it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including deep cleaning (S/RP), replacements, extractions and any other restorations needed. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition. (Initials__________)

PERIODONTAL S/RP (DEEP CLEANING)

I understand that most common complications are pain, bleeding, tissue (gum) laceration, sensitivity to temperature or foods, swelling, ulceration (infection), tooth fracture, breaking of fillings. Reactions to fluoride treatment may be nausea and vomiting. (Initials__________)

FILLINGS

I understand that the most common complications are pain, sensitivity to temperature, fracture of tooth, nerve damage, damage to other teeth, occlusal (bite)

discrepancies, and TMJ complications. (Initials__________)

EXTRACTIONS AND SURGICAL EXTRACTIONS

I understand that having my tooth/teeth extracted is permanent. There are a number of risks involved in extractions. The most common are soreness, swelling, bruising, restricted mouth opening during healing, bleeding and infection. Other risks possible are: Dry socket, damage to adjacent teeth, sharp ridges or bone splinters (which may require additional surgery to smooth the area), portions of tooth/teeth remaining, numbness of lip, chin, gums or tongue that could last for days, weeks, months or very rarely permanently, and sinus involvement that could require medication and/or surgery to correct.

(Initials__________)

I understand that dentistry is not an exact science and therefore reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment that I have requested and authorized. I have been given the opportunity to have all my questions answered.

I hereby authorize Dr. Thomas Jourdan, Dr. Doug Brammer, Dr. Jarett Turney and their dental staff to proceed with and perform the dental procedures and treatments as have been explained to me. I understand this is only an estimate and subject to modification depending on unforeseen or un-diagnosable circumstances that may arise during the course of treatment. Any changes will be discussed with you before proceeding.

PATIENT: _________________________________________

Sig of Patient/Guardian: _______________________________________ Sig of DOC: __________________________________ DATE: _____________________________________________ WITNESS: ___________________________________