Dental Registration and Patient Health History

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TERMS AND CONDITIONS

We are committed to providing you with the best possible care. Our fees reflect our professional commitment to excellence. If you have insurance, we are happy to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our FINANCIAL POLICY.

All accounts are due and payable at the time of your visit (including your percentage after insurance coverage), unless satisfactory arrangements have been made with our front desk. We are pleased to offer a 5% discount for accounts paid in full at the time of service. Visa, MasterCard, or Discover Card are accepted, but no additional discount will be given, as we pay a credit card user fee.

On accounts which have established financial arrangements with our office, the payment is due upon receipt of the monthly statement. Any balance outstanding more than 90 days will accrue additional interest at a rate of 1.5% per month. There will be a minimum charge of $35 for any returned checks due to insufficient funds.

As a courtesy, we will file your insurance claims for you and assist in helping you receive your maximum benefits. It is your responsibility to verify with our office that we have your correct insurance information and to inform us if there are any changes with your provider. Remember, insurance reimbursement is a contract between you, your employer, and your insurance company. Ultimately, dental services are charged directly to you and you are personally responsible for all charges whether or not paid by insurance. This dental office cannot render services on the assumption that charges will be paid by an insurance company.

In order to use our time efficiently, keep our fees as low as possible, and best serve our patients, there may be a $50 charge for any missed appointments and/or appointments not cancelled 24 hours prior to the scheduled appointment time.

Assignment of Insurance and Release of Information:

(Name of Insurance Company)

and assign directly to Dr. Hagedorn all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. Dr. Hagedorn may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for the related services.

I also understand that in order to collect my debt, my credit history may be checked through the use of my Social Security Number or any other information I have given you. I agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred, including reasonable attorney’s fees. I have read the above conditions and agree to their content.

CONSENT FOR TREATMENT

After explanation by Dr. Hagedorn, I hereby authorize the performance of dental services upon the named patients and his judgment in carrying out those necessary procedures. I also authorize and request the administration of any anesthetics and x-rays as may be deemed necessary and advisable by the doctor.

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DENTAL HISTORY

              
                   

Check if you have had problems with any of the following:

DENTAL PREFERENCES

              
              
              
              

ALLERGIES

MEDICATIONS

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EMERGENCY CONTACT INFORMATION

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PATIENT MEDICAL/HEALTH HISTORY

              
    
    
    
    
              
              
              
              
              
              

I certify that the information I have provided is accurate and complete. I will not hold Dr. Hagedorn or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.