The Exchange Dental Group

39 Broadway Suite 2115, New York N.Y. 10006 – (212)422-9229- theexchangedentalgroup.com

Get Acquainted Questionnaire

In order for us to better serve you, please fill out the following information COMPLETELY

Name:
Address:
Social Security #
Date of Birth:
Home Telephone:
Business Telephone
Email:
Cell Phone:
Employer:
Occupation:
Whom may we thank for referring you?
Are you married?
Spouse’s name:

Emergency Contact

Name
Phone Number
Relationship to Patient:

For Patients with Dental Insurance

Primary Insurance

Insurance Carrier:
Group #:
Name of Insured:
Relationship to Patient:
SS#(or ID#)
DOB:

Secondary Insurance

Insurance Carrier:
Group #:
Name of Insured:
Relationship to Patient:
SS#(or ID#)
DOB:
If patient is a student – Name of school:

I hereby authorize The Exchange Dental Group and its dentists to release to (Name of Insurance Company) or its representative, and information including the diagnosis and the records of any treatment or examination rendered to me during the period of such Dental care. I also authorize and request your company pay directly to The Exchange Dental Group the amount due to me in my pending claim for dental treatment or services, by reason of such treatment or services rendered.

Signature of Insured:

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Date:

MEDICAL HISTORY

Are you currently under the care of a physician?
Please explain
Are you taking any prescription / over the counter drugs?
Please list each one
Preferred Pharmacy Address and Phone Number:
For Women: Do you take any form of birth control?
Which kind?
Are you pregnant?
How many weeks?
Are you nursing?

Do you have or have you ever had any of the following diseases or medical problems? If NO, please select NO

AIDS
Pacemaker
HIV
Glaucoma
Colitis
Artificial Joints
Rheumatic Fever
Mental Disorders
Heart Surgery
Emphysema
Blood Transfusion
Sinus Problems
Ulcer
Hospitalized
Cancer
Anemia
Psychiatric Care
Kidney Disease
Heart Attack
Congenital Heart Lesions
Asthma
Seizures
Migraines
Hemophilia
Epilepsy
Stroke
Venereal Disease
Why?
Fainting or dizziness
Chemotherapy
Arthritis
Radiation Treatment
Liver Disease
Heart Murmur
Diabetes
Shingles
Bleeding abnormally, with extractions or surgery
Mitro Valve Prolapse
Herpes
Thyroid Problems
Hepatitis
High Blood Pressure
Fever Blisters
Crohn’s Disease
Artificial Heart Valves
Respiratory Disease
Low Blood Pressure
Heart Problems
Difficulty Breathing
Blood Disease
Shortness of Breath
Nervous Problems
Tuberculosis
type?
If YES to any of the above, please explain:
Please list any other serious medical condition(s) that you may have ever had:

Are you allergic to any of the following drugs? If No, please select NO

Penicillin
Codeine
Tetracycline
Ibuprofen
Latex
Erythromycin
Aspirin
Dental Anesthetics
Sulfa Drugs
Please list any other drugs that you are allergic to:

I affirm that the information that I have given today is correct to the best of my knowledge. I understand that The Exchange Dental Group safeguards my information in accordance with the HIPPA guidelines. I also understand that it’s my responsibility to inform the office of ANY changes in my medical history.

I authorize, with informed consent The Exchange Dental Group to perform any necessary dental services to help maintain my oral health, including diagnosis and treatment.

Signature

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Date

DENTAL HISTORY

Please check any of the following problems that apply to you:

If you could whiten your teeth for a cost anyone could afford, would you do it?

Do you smoke or use chewing tobacco?
How much? day, OR week
For how long?
Any current or history of drug or alcohol abuse?
Socially?

Do you have or have you had any of the following?

If you could change your smile, you would:

Please share the following dates:

Your last cleaning / /
Your last oral cancer screening / /
Your last complete x-rays / /

On a scale of 1-10, with 10 being the highest rating:

How important is your dental health to you?

Where would you rate your current dental health?

Name of Previous Dentist:
City:
State:
Phone Number:
Why did you leave your previous dentist?
What is the most important thing to you about your future smile and dental health?
What is the most important thing to you about your dental visit today?

I affirm that the information that I have given today is correct to the best of my knowledge. I understand that The Exchange Dental Group safeguards my information in accordance with the HIPPA guidelines.

I authorize, with informed consent The Exchange Dental Group to perform any necessary dental services to help maintain my oral health, including diagnosis and treatment.

Signature of Dentist

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Date:

Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers
  • Conduct normal healthcare operations such as quality assessments and physician certifications

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Name of Patient:
Date :
Signature of Parent/Guardian

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Other Individuals Allowed Access To My Records:

Spouse
Mother
Father
Son/Daughter
Significant Other
Other

Financial Policy

The Exchange Dental Group strives to be punctual; therefore we ask that our patients keep their appointments and also arrive on time. If a patient must cancel an appointment, we require at least 24 hour notice, with the exception of Sunday appointments, which must be canceled by Friday 12pm the latest. There is a $50 charge for late cancellations.

The Exchange Dental Group will make every effort possible to assist our patients with their insurance, however please keep in mind that dental insurance is a contract between the insurance company and the patient, not the dental provider. It is up to the patient to fully understand his/her benefits to ensure the appropriate disbursement of benefits under the terms of each individual plan.

It is the patient’s responsibility to notify The Exchange Dental Group should there be any change in the insurance plan. It is also the patient’s responsibility to notify us of any dental procedures that have been done in other dental offices that may reduce the insurance benefits available for the year.

As a courtesy to our patients, The Exchange Dental Group provides a treatment plan of which includes an estimate of the recommended treatment, the expected coverage from the dental coverage as well as the patient’s copayment respectively. Benefits quoted to you are only an estimate provided by the insurance company and not a guarantee of payment or eligibility at the time the services are performed. The Exchange Dental Group will submit claims and accept the assignment of benefits from the insurance company on behalf of the patient provided the patient pays their co-payment for each visit, due at the time of treatment, unless prior arrangements have been made, as we offer various financial programs to assist our patients with affordable monthly payments.

In the event that the claim is not paid by the insurance company within 30 days, the balance becomes the patient’s responsibility and is due immediately. Any balances that remain unpaid after 90 days will be referred to a third party for collections. * Please note that a $25 returned check fee will be added to the balance for all unpaid checks.

A misunderstanding can be an obstacle in establishing a successful relationship. If at any time you have a question regarding treatment, fee or service, please discuss it with us promptly and openly.

I, the undersigned, have read and understood the above and I consent to all the terms and conditions set forth in this agreement.

Signature

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Date