Insurance Information & Payment

Patient Name:

Birth date:

Soc.Sec.#

Address:

City:

State:

Zip Code:

Cell Phone#:

Email:

Home Phone#:

Employer:

Work Ph:

Marital Status:

Person responsible for payment:

Address:

Home Ph:

Spouse (or parent's) name:

Spouse (or parent's) employer:

Work Ph:

Who referred you to our office?

Have you ever had root canal treatment?

Are you nervous about your visit with us today?

Does your family dentist normally use nitrous oxide (laughing gas) when he/she treats you?

Would you prefer to use nitrous*?

*There is an additional charge due at time of visit

Patient Symptom Survey

Please answer these questions concerning the symptoms or problems you are having with the tooth or area in question.

Name:

Date

Please circle the tooth location:

upper

lower / (Your)

right

left

Have you had a root canal on this tooth before:

yes

no

If yes, how long ago?

Is there a crown on the tooth:

yes

no

If yes, how old is the crown?

How long has the tooth been hurting?

Was it due to trauma:

yes

no

If yes, explain:

Is the tooth sensitive to heat?

yes

no

Is the tooth sensitive to cold?

yes

no

Does it hurt to chew or put pressure on the tooth?

yes

no

Does it hurt for no reason?

yes

no

Does the pain keep you awake or wake you up at night?

yes

no

Are you taking over-the-counter medications for the pain?

yes

no

If yes, please list which medications and how often:

Are you taking any medications prescribed by your dentist?

yes

no

If yes, please list the prescriptions and when you began taking them:

Have the prescription medications helped?

yes

no

Office Payment Policy

The best patient-doctor relationships are maintained when there is a complete understanding of the treatment rendered and the fee. We feel that our work and equipment are of the highest quality. Our objective is to free you of pain in minimal time. Note that our office requests that your treatment be paid for at the time it is provided.
‍
INSURANCE:
We will file your insurance claim as a courtesy to you. The patient, not the insurance company, is responsible for the payment of fees for our services.
‍
BILLING:
Any account over 30 days past due will be assessed a monthly billing charge equal to 1 1/2% of the unpaid balance. (18% annually)
‍
METHOD OF PAYMENT:

Cash

Visa or mastercard

Discover

Care credit

I have read and understand the payment policy. I understand that the responsibility for payment for dental services provided in this office for myself or my dependents is mine. I agree to pay all collection fees, attorney fees or court costs required in the process of collecting a delinquent account. I hereby waive all rights to exemptions as to personal property that I may have under the Constitution of the State of Alabama.

Signature

Date

Witness

Date

IF YOU HAVE DENTAL INSURANCE
Please help us with the following:

Insured person's name:

Address:

Birth date:

Soc.Sec.#:

ReI. to patient (spouse, parent, etc.):

Name of Plan:

Address of Insurance Carrier:

Insurance Carrier Phone:

Group Number:

Contract Number:

Patient Information

Patient Symptom Survey

Office Payment Policy