EMERALD ISLE SMILES DENTAL STUDIO WELCOMES YOU ~We Are Honored by Your Call for an Appointment~ A warm welcome from Emerald Isle Smiles Dental Studio! Thank you for choosing us to contribute to your dental health and well-being. We value your opinion and will always appreciate you as a patient in our practice. We welcome any questions, concerns or suggestions you have about our services or office protocol. We take pride in two things: a patient s overall experience and the quality of our work. To us these are inseparable. Quality is critically important to us because for us it s not enough to say we care, but also to demonstrate our commitment. Our mission of caring directs everything in our office including taking advanced, specialized training in major areas of dentistry so that we can provide a full-range of treatment, including preventive, restorative, temporomandibular joint and muscle disorders, determining causes and providing solutions to worn and broken teeth/occlusal disease, Invisalign and cosmetic dentistry. In order to prevent dental disease, the active disease needs to be evaluated and eliminated. Therefore, it is crucial to have a complete picture of your present oral conditions, as well as insight into your dental and medical history. To help us with this, please fill out the enclosed patient registration and medical history. We will need to take the necessary x-rays to make our assessment in conjunction with making a thorough evaluation of existing conditions, establish a baseline and determine any potential problems by providing a screening for oral cancer; assess how your TMJs, muscles, and your bite are working together; analyze your gum and bone health; and survey each tooth one-byone. At times there can be several findings and concerns discovered in the comprehensive exam process that may require Dr. Myers to have you return for a short, free consultation to review and prioritize her findings more thoroughly as well as have adequate time to discuss treatment options without haste. This would simply be to avoid causing an overwhelming or confusing situation. Should this occur, Dr. Myers will set aside time for this consultation in conjunction with an appointment for some initial treatment in order to maximize the time you are visiting our office. It is our obligation as your dental healthcare provider to diagnose, discuss and present you with our findings. We feel it is important to make recommendations for treatment, discuss the investment in time and money involved and mutually decide which path to take. We are here to guide you in the decision process when it comes to treatment with careful consideration of your wants and needs. Again, it is our pleasure to have you join our dental practice! We look forward to seeing you! Sincerely, The Emerald Isle Smiles Dental Studio Team
PATIENT INFORMATION Patient Name: Date: Last First MI (Preferred Name) Gender: Family Status: Social Security #: Birth Date: Phone (Home): (Work): (Cell): Address: Street City State Zip Code Email: Preferred Method of Contact: Email Home phone Cell Phone Work Phone Emergency Contact: Phone: Responsible Party and Insurance Information The Following is for: the person responsible for payment the policy holder Name: Relationship to Patient: Last First MI Gender: Family Status: Social Security #: _ Birth Date: Phone (Home): (Work): (Cell): Address: Street City State Zip Dental Insurance Company: Subscriber ID: Insurance CO. Phone #: Employer Name: Referral Information Whom may we thank for referring you to our practice? Another Patient Dental Office Website Newspaper Other: Name of person or office referring you to our practice: Consent for Services 1.) I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis. Initial: 2.) Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. Initial: 3.) I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital on any possible complication. Initial: 4.) I agree to be responsible for payment of all services on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 7% late charge may be added to my account. Initial: 5.) I hereby give the doctor the absolute right and permission to use my photograph/slides for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides. Initial: 6.) I acknowledge that I reviewed the Emerald Isle Smiles Dental Studio s HIPAA and Notice of Privacy Practices. A copy is available upon request. Initial: Signature of Patient, Parent or Guardian Date Relationship to Patient
Emerald Isle Smiles Dental Studio asks that all patients carefully take the time to fully complete these medical and dental history informational forms. Our office is dedicated to providing complete dentistry for your well-being. It is important that we are provided with as much information as possible. Medical Information Have you had any of the following? Please check those that apply: AIDS Alcohol Use Allergies: Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer: Drug Use Ear Problems Eating Disorders Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries HPV High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy Due Date: Rheumatism Sinus Problems Stomach Problems Heart Disease Radiation Treatment Diabetes Heart Murmur Respiratory Problems Dizziness Hepatitis Rheumatic Fever Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain: Are you now under the care of a physician? Yes No If yes, please explain: Name of physician: Phone: Do you have any health problems that need further clarification? Yes No If yes, please explain: Stroke Tuberculosis Tumors Ulcers Codeine Allergy Penicillin Allergy MEDICATIONS: ORAL CANCER RISK ASSESSMENT CIRCLE ONE EXPLAIN Y N Do you smoke tobacco? Y N Do you chew tobacco or snuff? Y N Do you have excessive sun exposure to your face? Y N Do you drink more than 2 or 3 alcoholic beverages per day? Y N Do you have sores in your mouth that do not heal? Y N Is your voice hoarse for a prolonged period of time? Y N Do you have any lumps or thickening in your mouth or neck? Y N Do you have constant sore throats or feel like something is caught in your throat? Y N Is your diet poor and deficient in essential vitamins and minerals? Y N Do you have difficulty chewing or swallowing? Y N Do parts of your tongue or mouth feel numb? Y N Do you have areas of swelling in your mouth? Y N Do you wear dentures and have sore spots that won t go away? Y N Does your tongue or other parts of your mouth deviate to one side when you try to move them?
Purpose of initial visit: How long ago was your last dental visit? Do you have any current dental problems? Do you require medication prior to dental treatment? Are your teeth sensitive? Do your gums bleed or hurt? Have you noticed any mouth odors or bad tastes? Does food get caught between your teeth? Do you experience dry mouth? Do you floss daily? Have you ever had gum treatment or surgery? Have you ever seen a Periodontist? Do you sip energy drinks, juice or soft drinks all day? Do you gag easily? Dental History Name of previous dentist: When was your last dental cleaning? Y N Details Have you ever had an upsetting dental experience? Are you happy with the appearance of your teeth? Do you feel nervous about having dental treatment? Have you ever had complications with dental treatment? Have you ever had Orthodontic treatment? Would you like to keep your teeth all of your life? Do you clench or grind your teeth or ever been told that you do? Have you been told you have a TMJ problem? Does your jaw ever click or pop? Has your jaw ever locked open or closed? Do you wear a night guard? Do you have frequent headaches? Do you have worn, broken or cracked teeth or fillings? Have you ever had an injury to your chin or jaw?
Do you snore loudly? Have you been told that you gasp for air, snort or stop breathing during sleep? Do you have difficulty concentrating or staying awake during the day? Do you have or are you being treated for high blood pressure? Health Risk Assessment Y N Y N Is your BMI more than 35kg/M2? If not known, list your height and weight. Are you over the age of 50? Is your neck size greater than 16 inches? Is your gender Male? Have you been diagnosed with sleep apnea? Do you wear a C-Pap or sleep appliance? Are your tonsils present? Describe your sleep position: Side Front Back To the best of my knowledge, all of the preceding answers and information provided are true and correct. If ever I have any change in my health, I will inform the doctor at the next appointment. Print Name Signature of Patient, Parent or Guardian Date Staff Notes
PATIENT PRIVACY RELEASE FORM I consent to disclosure of the following protected health information about me to the following family members, medical or dental providers (involved in my dental care such as referring doctors), or persons (insurance companies) involved in my care or payment of my care for the following that may apply: All dental/medical information Information necessary to schedule appointments for me Lab results/radiographs Information necessary to provide for calling in or picking up prescriptions Information necessary to my family members, persons, and dental/medical providers Information necessary to bill for or submit claims for care provided for me by my dental insurance or FSA accounts I authorize this Health Provider and/or staff to leave medical or account information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes: Home/Cell Telephone Work Telephone Yes No Yes No Please list names of authorized persons: RIGHTS OF THE PATIENT I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed in this document by sending written authorization to Aubrey E. Myers, DDS. I understand that a revocation is not effective in cases where information has already been disclosed, but will be effective going forward. I understand that I have the right to refuse to sign this authorization and that any treatment will not be conditioned on signing this authorization. This authorization shall be effective until revoked by the patient or representative signing the authorization. Signature of Patient/Parent/Guardian Date
RECORDS RELEASE FORM I,, authorize Emerald Isle Smiles Dental Studio to Request the following records from my previous dentist. Previous Dentist: Name: Address: City: Phone: Fax: Please note that Emerald Isle Smiles Dental Studio is requesting the following records: All x-rays from the past five years All perio readings Recommended treatment and treatment plans Signature Date *Note to patients: Please send this form back either by fax to: 252.354.4688 or scan and email to drmyers@aspidamail.com before your appointment. *Note to doctor: Emerald Isle Smiles Dental Studio is a chartless office and would prefer that the above records be sent via email to drmyers@aspidamail.com. Records may also be sent to the below address: 8914 Reed Drive Suite C Emerald Isle, NC 28594
OFFICE FINANCIAL POLICY So that our office may keep administrative costs as low as possible and continue to provide quality care to our patients, we have developed the following guidelines to follow when making financial arrangements for our patients. Our intention is to eliminate any confusion our patients may have with regards to how they may pay for any necessary treatment. 1. We accept MasterCard, Visa, Discover, American Express for payment of any treatment. 2. We accept cash or personal checks, however we cannot accept third-party checks or checks that are post-dated. 3. Our office is not able to finance payments any longer than the length of treatment. We are able to accept an initial payment of one-half to one-third of the balance at the start of the treatment with the remaining balance to be paid upon completion of the treatment. We ask all emergency patients not of record to pay all charges in full at the time service is rendered. 4. Patients who require monthly installments past the length of their treatment are offered financing through CareCredit, a third-party company. 5. A deposit of half the amount of treatment planned may be requested if the appointment time is greater than two hours. 6. Current patient balances without proper financial arrangements will have specific arrangements made and placed in writing to be approved by the financial coordinator before any additional treatment can be provided. All new services will be rendered under the current financial policy. We are able to accept the assignment of insurance benefits from a patient s primary insurance carrier and require all insurance deductibles and co-payments be paid at the time service is provided. 7. Any account balance over 30 days will be considered past-due and could be sent to collections. 8. No discounts are offered, unless specified by the doctor. There can be no exceptions to this policy in order to stay within insurance guidelines. 9. All patients will receive an invoice, indicating any service provided or payment. 10. Adults (regardless if they are the child s parent) who escort minor children to the office are required to pay for any services provided. 11. Our office is not a provider for Medicaid. 12. Services provided through Workers Compensation Insurance must be coordinated and approved by the doctor and the patient s employer prior to the start of any treatment. 13. In the event of a divorce and/or separation, each adult is responsible for any services provided individually or to their children in accordance with the financial arrangements policy of the office. 14. Unless specific financial arrangements have been made to indicate otherwise, it is the official policy of this office that all services are to be paid in full at the time treatment is rendered. When insurance benefits are to be utilized, the estimated portion will be expected to be paid at time of service. The patient s dental insurance will then pay the office our portion. Should there be a balance, a monthly statement will be sent to the patient for the remaining amount owed. 15. If the insurance payment portion is greater than estimated, this amount will be credited to the patient s account. The patient may request a refund of that amount or be applied to future dental treatment. 16. Our office will file your dental claim form for you with the understanding that the office cannot guarantee coverage. 17. It is the patient s responsibility to be familiar with one s dental insurance plan and any variations or changes that may occur. Although our office participates with most insurance plans, we may not always know what each plan is going to pay. The office will estimate these portions to the best of our ability for each patient. 18. Our financial coordinator will gladly estimate your portion for each dental visit. If you are in need of a more accurate estimate, the office will submit for a predetermination on a patient s behalf. This typically takes 2-3 weeks to receive notice once submitted. 19. The office offers a yearly dental savings/membership plan for patients that don t have a dental insurance plan or wish to discontinue utilizing dental insurance.
APPOINTMENT POLICY It is important for patients to keep their dental appointments. We at Emerald Isle Smiles Dental Studio understand that you may sometimes need to reschedule appointments. If you must reschedule, we respectfully ask for scheduled appointments to be changed at least 48 hours in advance. Dr. Myers and our team strive to be available for your dental needs and the dental needs of all of our patients. When an appointment is scheduled for you, the office and staff reserve exclusive time for your care. Missing a dental appointment or cancelling a dental appointment without enough notice prevents us from giving you the care you need in a timely and planned manner. Also, broken appointments result in lost time that could have been used to provide care to other patients that are in need. Although there may not have been an appointment policy previously, circumstances have caused us to enforce such policy. As of February 15, 2018, our Appointment Policy will be as follows: We now require a minimum of 48 hours notice when cancelling an appointment. This may be via a Phone Call and/or Voicemail to: 252.354.4688, or by Emailing to: drmyers@emeraldisledentist.com. If you are to miss an appointment or cancel in less than 48 hours notice, a missed appointment will be documented in your dental record. Should a missed appointment occur, you could be subject to a missed appointment charge of $50 for that visit. In order to reschedule an appointment, you could then be required to make a deposit to reserve that new appointment. A reminder notification will be placed within 1 week of each appointment. Therefore, we will expect all appointments (not appropriately cancelled) to be attended at the scheduled time. In addition to the above, appointments must be confirmed within 24 hours of the appointment time. Should you miss our confirmation call and receive a message, please contact us as soon as possible to confirm. Note: Our office leaving a message with you does not qualify as confirmation. We are requiring that there be a response back from you. This may also be via a Phone Call and/or Voicemail to: 252.354.4688, or by Emailing to: drmyers@emeraldisledentist.com. Should your appointment go unconfirmed, your appointment could be at risk of being given to another patient. We will, of course, do our very best to still accommodate you. However, we may have to reschedule your appointment. Please know that you come highly valued as a patient of Emerald Isle Smiles Dental Studio, and we show appreciation for your understanding and cooperation as we institute this policy. We are also optimistic that this may never be an issue. Should you feel there is a better, more preferred way to contact you regarding your appointment or assist in helping you make your appointments, we certainly welcome any suggestions you may have. Our intention is to simply keep treatment plans flowing and achieve the quality dental health care goals we aim to achieve for everyone. From the Staff of Emerald Isle Smiles Dental Studio