ACME Dental - Intake Form
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Contact Information
First name
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Last name
*
Date of Birth
*
Gender
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Please select an answer
Male
Female
Other
Address
*
Postal Code
Home Phone
Cell Phone
Other Phone
Preferred E-mail
*
Occupation
How did you hear about us?
Search engine/Website
Signage
Social Media
Family member or friend
Other
The best thank- you we can receive is a referral! We want to make sure the person that sent you is appreciated!
Emergency Contact Information
Contact Name
*
Relationship to you
Home Phone
Cell Phone
Other Phone
Family Doctor Or Walk-In Clinic Information
Family Doctor
Phone
Address
Medical Care Card #
When was your last medical check-up?
Are you currently being treated for a medical condition?
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Yes
No
Are you currently taking any of the following medications:
ASA / Aspirin
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Yes
No
Warfarin / Coumadin / Heparin / Blood thinners
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Yes
No
Antibiotics
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Yes
No
Antidepressants
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Yes
No
Pain Killers
*
Yes
No
Anxiety Medication
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Yes
No
Birth Control
*
Yes
No
Please list current medications in the text box below or click on choose file to upload a list from your pharmacy
Only jpg or png files allowed. Maximum size 2MB.
Do you have any allergies?
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Yes
No
Are you sensitive or allergic to LATEX?
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Severely
Slightly
Not at all
I don’t know
Have you had any adverse reactions to medications?
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Yes
No
Have you had any adverse reactions to local anaesthetic? (dental freezing)
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Yes
No
Have you ever been hospitalized for ANY REASON? If so, when and why
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Yes
No
Do you currently smoke?
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Yes
No
Have you attempted to quit?
Yes
No
Are you pregnant?
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Yes
No
Is there any chance you could be pregnant?
*
Yes
No
Are you currently breastfeeding?
*
Yes
No
Do you currently have any of the following conditions (please check all that apply)
heart disease (attacks, arteriosclerosis, angina)
congenital heart defects
pacemaker
fainting
seizures
hepatitis, jaundice, or liver disease
tuberculosis
HIV positive
lung disease
autoimmune disease
kidney disease
cancer
dry mouth
asthma
seasonal allergies
hives or skin rash
psychiatric care
depression
blood disorder anemia, clotting, hemophilia
herpetic lesions (cold sores)
HPV
drug dependency
alcohol dependency
diabetes
frequent headaches
frequent thirst
high blood pressure
low blood pressure
hip replacement
joint replacement
arthritis
Do you have any concerns when visiting the dentist? If yes, please list below:
Insurance Information
Primary Dental Insurance Provider
Employer
Policy or Group #
ID or Certificate #
Plan Holders Name
Plan Holders Date of Birth
Basic Coverage %
Major Coverage %
Annual Limit $
Recall Schedule
Root Planning & Scaling Units
Yearly Deductible
Yes
No
Are composite (white) fillings covered on molar teeth?
Yes
No
Secondary Dental Insurance Provider
Employer
Policy or Group #
ID or Certificate #
Plan Holders Name
Plan Holders Date of Birth
Basic Coverage %
Major Coverage %
Annual Limit $
Recall Schedule
Root Planning & Scaling Units
Yearly Deductible
Yes
No
Are composite (white) fillings covered on molar teeth?
Yes
No
I authorize release; to my dental benefits plan administrator and the CDA, to release information contained in claims and preauthorizations submitted electronically and manually. I also authorize communication of information related to the coverage details and services described to the named dental office.
This authorization shall continue in effect until the undersigned revokes the same.
Assignment of benefits
I hereby assign my benefits, payable from claims submitted electronically and manually, to the treating doctor at ACME Dental and authorize payment directly to him/her.
This authorization shall continue in effect until the undersigned revokes the same.
I understand that ACME Dental is a third party company and that my insurance policy is an agreement between me, my employer and the insurance company. I understand that though ACME Dental has my plan on file and submits claims on my behalf, that I am ultimately responsible to know my plans details and guidelines and that I am financially responsible for any treatment not covered under those guidelines.
OFFICE POLICIES
All patient balances are due immediately after treatment is rendered.
Should a balance accrue on the account a statement will be sent and payment is to be made, in full, within 15 days of the date on the statement. If payment is not paid within 30 days interest at the rate of 1.5% per month will be applied to the entire account balance. A revised statement with the new account balance, payable immediately, will be sent.
If no effort is made to clear the account within 90 days of the initial statement date a $50 dollar administration fee will be applied and the account will be sent to collections. All booked appointments will be cancelled and no further appointments will be booked. This applies to all patients on or connected to the delinquent account.
A $20 NSF fee is applied to all patient cheques rejected by the financial institution.
Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by the dentist, not an obligation. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.
If there is dental insurance on the account, I understand that the clinic has established the patient balance based on the information I have provided. Final treatment payment is subject to the terms and conditions of my insurance provider on the date of service. As such, until payment is received from my insurance provider, no patient payment is final.
Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total.
Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics.
A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.
As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The clinic will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible. The clinic will make every effort to accommodate my scheduling needs.
I have a time reserved for my appointment. ACME Dental requires that any changes to appointments are made with a minimum of two full business days between the day I am calling and the day I have reserved. If I do not keep the appointment and/or fail to notify the clinic with the required notice, a $125 refundable rebooking deposit will be required in order to reserve any further appointments. If I fail to arrive for an appointment on a Saturday, I will no longer be able to reserve Saturday appointments unless I pay a $125 fee.
That appointment cancellations and/or rescheduling must be communicated directly to a representative of the clinic. Cancellations and/or rescheduling are not accepted via email or phone message and if done so the above noted cancellation fee will apply.
To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information may be dangerous to my (or patients) health.
Signed by
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Please leave this field empty
I have reviewed the privacy consent policy (
click here to review
).
*
Full Name
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