Fill out the form below and submit it to our office.

Health History & Registration

Date 

PATIENT INFORMATION

DOB 
Is patient a full time student?
YesNo
Your Preferences

Do you prefer appointment reminders by:

Email Phone Text

Do you prefer to receive calls from our office at:

Home Work Cell

Responsible Party Information

Same as Patient
DOB: 

Insurance Information

MEDICAL INSURANCE:

None
Same as Patient
DOB:

SUPPLEMENTAL INSURANCE (DENTAL):

None
Same as Patient
DOB:

Secondary DENTAL Insurance:

None
Same as Patient
DOB:

Medical History and Consent

Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health conditions or problems that you may have or had, or medications that you may be taking, could have an important interrelationship with the treatment you will receive. Thank you for answering the following questions.
Allergies:
Acrylic
Anaphalaxis
Local Anesthetic
Metal
Latex
sulpha
Penicillin
Cardiovascular
Artificial Heart Valve
YesNo
Coronary Artery Disease
YesNo
Chest Pain or Angina
YesNo
Congestive Heart Failure
YesNo
Heart Attack
YesNo
Heart Murmur
YesNo
High Blood Pressure
YesNo
High Cholesterol
YesNo
Irregular Heart Beat
YesNo
Low Blood Pressure
YesNo
Mitral Valve Prolapse
YesNo
Pacemaker
YesNo
Tachycardia
YesNo
Endocrine
Diabetes
YesNo
Hormonal Change
YesNo
Gout
YesNo
Thyroid problems
YesNo
Eyes, Ears, Nose and Throat
Change in Hearing
YesNo
Change in Vision
YesNo
Dysphagia
YesNo
Ear Pain
YesNo
Glaucoma
YesNo
Hay Fever
YesNo
Nasal Obstruction
YesNo
Nose Bleeding
YesNo
Sinus Problems
YesNo
Tonsillectomy
YesNo
Tinnitus (Ringing)
YesNo
Gastrointestinal
Acid Reflux
YesNo
GERD
YesNo
Soft or Special Diet
YesNo
Ulcers
YesNo
Genitourinary
Frequent Urination
YesNo
Nocturia
YesNo
Kidney disease
YesNo
General
Current weight:
Height
ft
in
Cancer
YesNo
Fatigue/Tired
YesNo
General Weakness
YesNo
Headaches
YesNo
HIV/AIDS
YesNo
Knee/hip replacement
YesNo
Liver problems
YesNo
Recent Trauma or Injury
YesNo
Rheumatic Fever
YesNo
Radiation Treatment
YesNo
Weight Change
YesNo
Hematological
Bleeding problems
YesNo
Hepatitis
YesNo
Oral
Bleeding gums
YesNo
Dry mouth
YesNo
Jaw problems (TMJ)?
YesNo
Clicking?
YesNo
Pain?
YesNo
Difficulty swallowing?
YesNo
Difficulty chewing?
YesNo
Orthodontics or Invisalign
YesNo
Do you wear removable teeth?
YesNo
Periodontal Disease
YesNo
Teeth clenching
YesNo
Teeth grinding
YesNo
Teeth pain
YesNo
Wisdom teeth extraction
YesNo
Do you wear removable teeth?
YesNo
Do you take or need antibiotics before dental procedures?
YesNo
Musculoskeletal
Back Pain
YesNo
Joint Pain
YesNo
Fibromyalgia
YesNo
Neurological
Alzheimer’s Disease
YesNo
Dizziness
YesNo
Fainting
YesNo
Memory Loss
YesNo
Multiple Sclerosis (MS)
YesNo
Muscle Weakness
YesNo
Seizures
YesNo
Stroke
YesNo
Tingling or Numbness
YesNo
Trigeminal Neuralgia
YesNo
Tremor
YesNo
Psychiatric
ADD/ADHD
YesNo
Anxiety
YesNo
Chemical Dependency
YesNo
Depression
YesNo
Eating disorders
YesNo
Excessive Stress
YesNo
Memory problems
YesNo
Respiratory
Asthma
YesNo
Bronchitis
YesNo
Breathing problems
YesNo
Chest Pressure
YesNo
Congestion
YesNo
Dyspnea (shortness of breath)
YesNo
Emphysema
YesNo
Orthopnea
YesNo
Pneumonia
YesNo
Pulmonary Embolism
YesNo
Tuberculosis
YesNo
Sleep
Daytime Sleepiness
YesNo
Morning headaches
YesNo
Obstructive Sleep Apnea
YesNo
Do you use a CPAP?
YesNo
How often?
Has anyone told you that you snore?
YesNo
Social History
Do you smoke?
YesNo
packs a day
Do you use smokeless tobacco?
YesNo
Do you consume alcoholic beverages?
YesNo
Drinks per day/week/month
Do you use recreational drugs?
YesNo
List any medications you are taking:
Medication
Dosage/Freq.
Prescriber
Reason
List any surgeries or hospitalizations you have had:
Date(year)
Surgery
Surgeon
Reason
Are you under the care of other physicians? If so, please list:
Physician
Phone #
Reason
GENERAL CONSENT TO DIAGNOSE AND TREAT:The undersigned hereby authorizes Dr. Tontra Lowe or her representative to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient’s dental condition and needs. I authorize Dr. Tontra Lowe to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Dr. Tontra Lowe choose and employ such assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Dr. Tontra Lowe. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status.
FINANCIAL CONSENT:I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. I understand that I am responsible for any portion of fees for services rendered not covered by my dental or medical insurance (if any). I further consent to and agree to pay a 1 1/2% finance charge (18% annually) that will be applied to any balance over 60 days. I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Dr. Tontra Lowe and her staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits payable to her, and to handle any necessary claim appeal(s) on my behalf.
Consent (adult):
Date 
Consent (for a minor child):
Date 
Notice of Privacy Practices (below)
Patient privacy is important to our practice. We are required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. By signing below you are acknowledging receiving notice of our practices’ policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company (if applicable), my other medical providers, and
Date 
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I certify that I and/or my dependent(s) have insurance coverage with and assign directly to Dr. Lowe all insurance benefits, if any, otherwise payable to me for services rendered. I understand I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Date 

Financial Agreement

We pride ourselves on offering the best customer service available, and will gladly submit your claims to any insurance company you prefer. Remaining payment of the patient’s portion is due no later than the day the dental service is rendered except for extensive treatment, Six-Month Smiles treatment and Clear Aligners. Patients may require specific financial arrangements for any and all treatment.

All treatment plan costs presented are ESTIMATES only; I will be responsible for the applicable financial differences. I understand that my specific policy is an agreement between the insurance company and me, and I am responsible for any financial differences. Should for any reason the insurance benefits result in less that the coverage anticipated, I understand that I am the responsible party for the total obligation.

Every effort is made to bill my insurance directly for reimbursement; however, if they do not pay within 60 days, I am still responsible for all remaining treatment fees. If I fail to notify Awesome Smiles of any insurance change, I will be fully responsible for any amount not paid by my insurance.

I agree to pay finance charges of 1.5% per month (18% APR) on any balance 60 days past due. If sent to collections, I agree to pay all related fees and court costs. Any check not cleared through the bank and returned to our office because of an insufficient balance will incur to the patient a $35.00 service fee.

There are many times that our patients require urgent or emergency treatment and therefore require an appointment as soon as possible. When patients give the office advance notice of their need to cancel a scheduled appointment, this time can then in turn be allocated to these patients in urgent need of treatment. In this way the office can best serve the needs of ALL patients. With this in mind, a fee of $75/person/30 min is charged for patients who cancel without a 48-hour notice, which does not include after office hours, weekends, text, or email. We cannot access text messages and email is only available during office hours. For sedation patients, a 72-hr notice is required.

To reserve time with the doctor, a portion of the patient's co-pay is due at the time of scheduling. Any remaining payment is due on the day the dental service is rendered except for extensive treatment, Six-Month Smiles treatment and Clear Aligners. Payment Options: Cash, Check, Visa, Mastercard, Discover, CareCredit (not all co-pays qualify), and Lending Club (allows payments over time with little to no interest)

Any medical payments sent directly to you mistakenly must be brought to the office within three (3) business days of receipt. Please make sure to bring the entire explanation of benefits with the payment to balance your account. Refunds are issued after all claims have been filed and all payments posted to your account. Failure to do so will result in collections initiated on your behalf.

We will bill all balances that remain on your account, after all insurance and co-pay amounts are applied, to your primary credit card on-file with the office. Please inform office personnel if you prefer to have a specific card used for billing. You will receive statement notification prior to any charges being applied. Emergency appointments after hours and on weekends incur an automatic $150 cash payment in addition to any treatment completed during the appointment. Failure to come to the scheduled emergency appointment will still incur the charge if the doctor is not notified and arrives to treat you, but you elect not to come.

Date 

Dear Patient:

Welcome to Awesome Smiles! We are so happy that you have chosen our office for your dental needs. You have certainly selected the right office, doctor, and team. We believe everyone should smile with confidence, not embarrassment, and we strive to make your visits with us the most comfortable possible.

In order for us to provide the ultimate patient experience each time you are here, we have prepared this letter to help you better understand the complexities of dental insurance; we realize how confusing it can be. To begin, we would like to highlight a misconception - dental insurance was not designed to pay for all dental care. Most contracts have limits and/or various degrees of co-payment.

All levels of payment by insurance companies, including allowed fees, usual and customary (UCR), are governed by the premiums paid. They have nothing to do with the actual charges. Our fees are based upon a combination of our costs, our time, and our constant dedication to supplying our patients with the highest quality dental care. The treatment recommended by our office is never based on what your insurance company will pay; your treatment should not be governed by your insurance contract. However, it should be understood, that the dental insurance contract is between the insurance company and the patient, who bears the ultimate financial responsibility.

Once you arrive at the office for your first appointment, we will happily provide you with a complimentary insurance benefits analysis that is extremely helpful to many of our patients. Please take the time to review the information we are providing, which is what we use to determine any coverage and fees. It will also benefit you greatly to study your contract thoroughly so we may best serve you. As always, you may feel free to ask any member of our staff for clarification on services, billing, and insurance.

Sincerely,

Dr. Lowe and Staff

Date 
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