Business letterhead stationery (Simple design)



Welcome to Cortez Family DentistryWelcome to our dental family at Cortez Family Dentistry.? Every day, our staff strives to provide the highest level of care for you and each of our patients. We’re pleased you have chosen our office to address your dental health. We look forward to caring for you. ?Financial PolicyWe appreciate the opportunity to serve you. Having a clear understanding of our financial policy may help to relieve some of the anxiety associated with dental visits. This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. All charges you incur for any treatment that is provided are your responsibility regardless of your insurance coverage. We will always recommend treatment based upon your dental needs, not based on insurance coverage, which can be inadequate with some dental plans. Dental insurance is a benefit used to assist you, not to dictate necessary treatment. Dental InsuranceWe accept all dental insurance and are a preferred provider for Delta Dental, MetLife, and Cigna. We will be happy to file your dental insurance claim as a courtesy to you. If there is any remaining balance after we receive payment from your insurance company, that balance will be due within 30 days of notification. Payment OptionsWe accept cash, check, Care Credit, Visa, MasterCard, and Discover. As a courtesy, we will bill your insurance and your copay is due at time of service. You may also use your Flexible Spending/Health Savings Account through your employer. With prior authorization, we can split your balance into three monthly payments. We are not a Medicaid provider, if you receive Medicaid benefits you can reach the Montezuma County Health Dept., 970-565-3056, for a list of all Medicaid providers.For patients without insurance, we offer a discount of 5% for procedures of more than $350 paid in full with check or cash. Payment with Visa, MasterCard, or Discover for procedures more than $350 will receive a discount of 2.5%. Payment is due at time of service unless other arrangements have been made. If you cannot pay in full at this time, please communicate with us. Failure to pay your account balance will result in the account being turned over to a collection agency, additional processing fees may be added at this time. We would like to use this measure as a last resort. There is a $30 charge for returned checks. Appointment PolicyWe value your time and always try to serve you in a timely manner. We ask that you extend the same courtesy in return. We understand that unplanned issues come up and you may need to reschedule an appointment. Should you need to reschedule an appointment, we ask that you contact us at with as much notice as possible. We strive to remain on schedule for all patients, therefore we may need to reschedule your appointment if you arrive 10 or more minutes after the scheduled appointment time.Patients who are habitually late or miss appointments will be placed on the tributary list. When an appointment becomes available, they will be called and given the opportunity to have the appointment. They will not be placed on the schedule in advance. Thank you for being a valued patient and for your understanding and cooperation with this policy. This enables us to open otherwise unused appointments to better serve the needs of all patients. If you have any questions, please ask. Kind regards, Dr. Ned Walker & Cortez Family DentistryI consent to be a patient at Cortez Family Dentistry and agree to a radiographic and clinical examination. I also understand and consent to the following:During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, oral pathology, pediatric dentistry, and radiography.Dr. Walker requires all patients to have radiographs every two years in order to give accurate and complete treatment.I have provided a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history, per HIPAA regulations.No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.I will pay in full any cost of treatment or insurance co-payments according to the office financial policy. I understand that even if an insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for any costs that my insurance does not cover. I understand that payment is due at the time of service, including my estimated portion. I hereby assign all dental benefits to which I am entitled. I hereby authorize and direct my insurance carriers to issue payment checks directly to Cortez Family Dentistry for dental services rendered to myself and/or my dependents regardless of my insurance benefits, if any. Cortez Family Dentistry will provide an estimate of insurance coverage upon request. I understand that Cortez Family Dentistry is not responsible for inaccurate estimates. Payments of a dental claim is not guaranteed by any insurance and is based on eligibility and policy coverage at the time a claim is submitted. I hereby authorize Cortez Family Dentistry to furnish and/or release personal information to insurance carriers, dental referrals, and pharmacies concerning my dental treatment or my dependent's dental treatment per HIPAA regulations. I will also allow a photocopy of my signature to be used to process my insurance claims or my dependent’s claims. This order will remain in effect until revoked by me in writing.My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.My time is valued and Cortez Family Dentistry will always try to serve you in a timely manner. Cortez Family Dentistry understands that issues come up and I may need to reschedule an appointment. Should I need to change a scheduled appointment, Cortez Family Dentistry respectfully asks that I contact the office with as much notice as possible or at least 24 hours in advance. We strive to remain on schedule for all patients, therefore we may need to reschedule your appointment if you arrive 10 or more minutes after the scheduled appointment time.I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.__________________________________________________________ _______/_______/__________Signature of Patient or Parent/Guardian Date__________________________________________________________Print Name of Patient or Parent/GuardianPersonal Information and Health HistoryPatient Name: ___________________________________________________________ Date: _____/_____/______Title: Mr.__ Mrs.__ Ms.__Gender: M__ F__ Family Status: Married __ Single __ Divorced__ Widowed __Child__Birthdate: _______/_______/__________ Social Security Number: __________-___________-___________Mailing Address: _________________________________ City: _________________ State:_____ Zip:_________ Physical Address:__________________________________________City:_____________________State:_______Phone C:(_______) _______-_____________ H:(_______) _______-__________W:(_______) _______-__________E-mail Address: (optional)_________________________________________________________________________ Contact Preference: Choose all that apply. Text____ Phone____ E-mail____ USPS Mail____Parent Name (for minors):_________________________________________________________________________ Whom may we thank for referring you?___________________________________________________Emergency Contact: ___________________________ Phone: ___________________Dental Insurance InformationInsurance Company:________________________________ Subscriber Name:________________________________ Subscriber ID/SSN:_________________________________________ Subscriber Birthday:_______/_______/_______Group Name:____________________________________ Group Number:___________________________________As a patient, understand that your dental insurance is a contract between you and your insurance company. Any remaining balance after claims have been processed by the insurance company is the responsibility of the patient.Dental History:Do your gums bleed while: Brushing Yes ______ No______ Flossing Yes ______ No______Are your teeth sensitive: Hot or cold liquids?Yes ______ No______ Sour or Sweet? Yes ______ No______Do you feel pain in any of your teeth?Yes ______ No______ Do you have lumps or sores in your mouth? Yes ______ No______Have you ever had a neck, head or jaw injury? Yes ______ No______Do you experience frequent headaches?Yes ______ No______Have you ever experienced difficult extractions?Yes ______ No______Any prolonged bleeding after extractions?Yes ______ No______Have you had orthodontic care (braces)?Yes ______ No______Have you ever had instructions on taking care of your gums? Yes ______No______Have you been instructed on the correct method of brushing? Yes ______No______Do you currently or have a history of the following issues with your jaw? (Circle all that apply.)Clicking Difficulty opening or closingDifficulty chewingClenching or grindingBite lips or cheeks frequentlyPainMedical HistoryPhysician: ___________________________ Phone: ____________________Last Exam: ______/______/_______Pharmacy: ____City Market ____Safeway ____Walgreens ____Walmart ____SWM HospitalCurrent and past conditions: (circle all that apply)High Blood PressureLow Blood PressureHeart Disease Heart Attack (Date:____/____/____ )Pacemaker Heart MurmurEpilepsy/Seizures AIDS or HIVLeukemiaDiabetesKidney DiseaseAcid Reflux/GERDSTDPre Diabetes Swollen AnklesEmphysemaAsthmaFatigueAnemiaTooth ImplantCancerArthritisJoint ReplacementUlcersHepatitis/JaundiceHypothyroidismStomach ProblemsChest PainsEasily WindedStrokeSeasonal Allergies Depression/Anxiety/Mental Health Diagnosis*TuberculosisRadiation TherapyGlaucoma Rheumatic FeverLiver DiseaseRespiratory IssuesRecent Weight Loss Other_________________________________ *** Medications to treat depression, anxiety, and other mental health conditions can be adversely affected when used in conjunction with anesthetic in our office. For your safety, please list all current medications. *** MedicationCondition??????????????Have you had a heart attack within the last six months? Yes NoHave you been hospitalized for surgery or serious illness? Yes NoPlease explain: ___________________________________________________________________________________Do you use: (circle all that apply):AlcoholTobaccoCocaine Marijuana Methamphetamine Recreational DrugsDo you currently take medication for osteoporosis, or have in the past? Yes NoBoniva Fosamax Aredia ActonelOther_____________Date started: ______/______/______ Date ended: ______/______/_______ Do you have allergies to any medications? Yes NoPenicillin Other Antibiotics Sulfa Drugs Barbiturates Other__________________Local AnestheticsIodine Aspirin Sedatives Women:Are you pregnant? Yes No Are you taking birth control: Yes No Are you nursing? Yes No Med:___________________ Device:______________________To the best of my knowledge the above information is complete and correct. I understand it’s my responsibility to inform Cortez Family Dentistry of any health changes for myself or my child/children._______________________________________________________ _______/_______/_______ Signature of Patient or Parent/Guardian Date_______________________________________________Print Name of Patient or Parent/Guardian ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download