Patient Intake Form

Patient Information

Family Status

Responsible Party Information (for minor children)

Family Status

Employment Information

Insurance Information

Please provide the receptionist with a copy of your insurance card or claim form.

Primary Dental

Patient's relationship to insured

Secondary Dental

Patient's relationship to insured

Dental Information

Are you having any dental problems, pain, or sensitivity?

Medical Information

Are you taking any medications now?
Are you allergic to any medications?
Do you have or have you had any of the following medical conditions?

Financial Policy

Thank you for choosing Amelia East Family Dentistry, Inc. as your dental care provider. We are committed to your treatment being successful. The following is a statement of our Financial Policy, which we require you read and sign prior to any treatment. All patients must complete our Information and Insurance form before seeing the dentist.

  • Payment of all insurance co pays and deductibles are due at the time of service.
  • We offer EXTENDED PAYMENT PLANS with prior credit approval.
  • Payment for non insurance patients is due at the time of service unless PRIOR arrangements have been made with the Office Manager.

Regarding Insurance

The balance is your responsibility whether your insurance pays or not. We cannot bill your insurance company unless you give us your insurance information and an original claim form or insurance card. Your insurance policy is contracted between you and your insurance company. We are not a party to that contract, in most cases. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges nor covered by insurance. Please be aware that some, and perhaps all, of the services provided may be non covered services and may not be considered reasonable and customary under your dental insurance policy. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary in our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Minor Patients

An adult must accompany minors to all appointments. The adult accompanying a minor and the parents or guardians are responsible for full payment of the minor's balance. Non-emergency treatment will be denied to any minor that is not accompanied by an adult.

Billing Information

All balances billed shall be paid in full at the first billing. There may be a re-billing fee for each additional billing cycle thereafter. If your account becomes past due, we will not be able to continue treatment until the balance is paid in full. If your account becomes past due, we will take the necessary steps to collect this debt. If we have to refer your account to a collections agency or lawyer, you agree to pay all collection costs and attorney fees. You understand if this account is referred to a collection agency or lawyer or if your past due balance is reported to a credit reporting agency, the fact that you received treatment at our office becomes a matter of public record. All returned checks will be collected by a collection agency and there will be fees associated with the collection process.

Transferring Records

You will need to request, in writing, and pay a reasonable copying fee if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

Missed Appointments***

Unless cancelled at least 24 hours in advance, there will be a $40 charge for all missed appointments. This fee must be paid before a new appointment is scheduled. For the convenience of our patients, we offer some evening and early morning appointments. Due to the high demand for these appointments, they are considered prime time appointments. If you do not cancel these appointments at least 24 hours in advance, we will bill the missed appointment charge and we will no longer be able to schedule you for a prime time appointment. Patients with three or more missed appointments will be asked to transfer their records to another doctor. Please help us serve you better by keeping all scheduled appointments.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

I have read the Financial Policy. I understand and agree to this Financial Policy

Dental Insurance Policy

Due to the many differences and constant changes in dental insurance policies, it is a difficult task to interpret each individual policy. Although, we try to stay aware and keep up with those changes, it is not always possible

Your dental insurance is a contract between you, your employer and your insurance company. In most cases, we are not a party to that contract. It is your responsibility to know what your policy covers. We bill your insurance company as a courtesy to you. Although, we may estimate what your insurance may pay, it is the insurance company that makes the final determination of your benefits. You are responsible for any and all charges regardless of what insurance pays.

We recommend that you contact your insurance company with any questions regarding what your insurance may cover on any particular procedure. Thank you for understanding our Dental Insurance Policy.

I have read, understand and agree to Dental Insurance Policy

HIPAA Acknowledgement

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointments, and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue preventative care, balances due, lab results, or any healthcare related information (PHI) regarding my healthcare events.

By signing this document, I understand the above information and agree with its contents.

Dental Care Warranty Agreement

It is our goal to provide you with highest quality dentistry, using the most up to date skills and the finest materials available. As such we provide a peace of mind warranty on all of our work. An exam and x-rays are needed to assess the area for warranty coverage. The cost of the exam and x-rays are NOT covered under the warranty.

Dental Treatment Guarantee of 1 years for the following treatment:

  • Composite (tooth colored), Amalgam (silver fillings)

Dental Treatment Guarantee of 2 years for the following treatment:

  • Crowns, Bridges, Inlays, Onlays, or Veneers
  • Dentures and Partials (adjustments included for the first 90 days)

This warranty covers the following conditions:

  • Broken restoration
  • Loose crowns, bridges, fillings, veneers, inlays or onlays
  • Cracked or discolored restorations
  • Lost fillings, crowns, bridges, veneers, inlays, or onlays

This warranty is voided if:

  • The patient fails to maintain the recommended recare schedule
  • The patient fails to have recommended hygiene recare completed in our office
  • The patient fails to complete the recommended dental treatment to maintain the restorations as directed by the treating doctor
  • The patient fails to keep their dental account in good standing

This warranty does not cover:

  • Damage caused due to grinding or bruxing (Doctor's determination)
  • Damage caused during the extraction of a neighboring tooth
  • Areas of the mouth restored by another office.
  • Damage caused by neglect, abuse, or poor hygiene
  • Damage caused by an accident
  • Secondary Decay
  • Acts of God

Dental Treatment Not Covered:

  • Root canal therapy- due to the complexity of the root anatomy and types of bacteria
  • Bone Grafting & Implant Surgery
  • Tooth Whitening
  • Dentures and Partial Dentures (adjustments included for the first 90 days)

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.