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

Health History & Registration

Date 

PATIENT INFORMATION

Date 

Residence

Mailing Address

Responsible Party Information

Residence

Mailing Address

DOB:

Insurance Information

Primary Insurance

DOB:

Secondary Insurance

DOB:
It is important that we know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

Dental History

Last COMPLETE Dental Exam:
Last FULL MOUTH XRAYS:
(16 Small Films or Panoramic)
Do you wear DENTURES? (Partials or Full)
YesNo
Are you UNHAPPY with your dentures?
YesNo
Would you like to know more about PERMANENT REPLACEMENT?
YesNo
Are you UNHAPPY with the APPEARANCE of your teeth?
YesNo
Would you like your smile to LOOK BETTER or DIFFERENT?
YesNo
Do you have DISCOLORED teeth that bother you?
YesNo
Do your gums BLEED, or feel TENDER or IRRITATED?
YesNo
Are your teeth SENSITIVE to hot, cold, sweets, or pressure?
YesNo
Does food get stuck in your teeth?
YesNo
Do you REGULARLY use DENTAL FLOSS?
YesNo
Are you aware of GRINDING or CLENCHING your teeth?
YesNo
Do you have HEADACHES, EARACHES, or NECK PAINS?
YesNo
Have you worn BRACES on your teeth (ORTHODONTICS)?
YesNo
Have you had any PERIODONTAL (GUM) treatments?
YesNo
Are you APPREHENSIVE about dental treatment?
YesNo

Medical History

Do you have any CURRENT HEALTH PROBLEMS?
YesNo
Are you under a PHYSICIAN'S CARE now?
YesNo
Have you ever taken:
Fen-Phen
Redux
Coumadin
Do you need to premedicate?
YesNo
Are you PREGNANT/NURSING?
YesNo
Do you use cigars/cigarettes, pipe, or chewing tobacco?
YesNo
Please select yes or no of the following which you have had or presently have:
AIDS/HIV Pos.
YesNo
AIS
YesNo
Anaphylaxis
YesNo
Anemia
YesNo
Arthritis (Rheumatism)
YesNo
Artificial Heart Valves
YesNo
Artificial joints
YesNo
Asthma
YesNo
Back Problems
YesNo
Blood Disease
YesNo
Cancer
YesNo
Chemical Dependency
YesNo
Chemotherapy
YesNo
Circulatory problems
YesNo
Cortisone treatments
YesNo
Cough (persistent)
YesNo
Cough up blood
YesNo
Diabetes
YesNo
Epilepsy
YesNo
Fainting
YesNo
Food allergies
YesNo
Glaucoma
YesNo
Headaches
YesNo
Heart murmur
YesNo
Heart problems
YesNo
Hemophilia (Abnormal bleeding)
YesNo
Herpes
YesNo
Hepatitis
YesNo
High blood pressure
YesNo
High cholesterol
YesNo
Jaw pain
YesNo
Kidney disease or malfunction
YesNo
Liver disease
YesNo
Material allergies
YesNo
Mitral valve prolapse
YesNo
Nervous problems
YesNo
Pacemaker/heart surgery
YesNo
Psychiatric care
YesNo
Rapid weight gain/loss
YesNo
Radiation treatment
YesNo
Respiratory disease
YesNo
Rheumatic/scarlet fever
YesNo
Seasonal allergies
YesNo
Shingles
YesNo
Shortness of breath
YesNo
Skin rash
YesNo
Spina bifida
YesNo
Stroke
YesNo
Surgical implant
YesNo
Thyroid disease or malfunction
YesNo
Tonsillitis
YesNo
Tuberculosis
YesNo
Ulcer/colitis
YesNo
Venereal disease
YesNo
Multiple sclerosis
YesNo
Are you allergic to or have you reacted adversely to any of the following medications?
Aspirin
Local Anesthetic
Erythromycin
Latex (Baloons, Gloves, etc)
Nitrous Oxide
Codeine
Penicillin
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 
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)

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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