The Exchange Dental Group

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

Please help update our records

Please full out the following information COMPLETELY

Name:
Address:
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 Patient:

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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

Payment Procedures for 30 Days After Dental Services

or

Receipt of Insurance Benefit Payment

I’ve been made fully aware that this is ONLY AN ESTIMATE, based on information provided to The Exchange Dental Group by my insurance company. I understand that my insurance company may pay more or less than the estimated amount. I am paying the estimated co-payment with the understanding that I am responsible for any balance that remains after the insurance company has paid its portion. If the insurance company pays more than the estimated amount, the difference will be refunded to me. If the insurance payment is less than the estimated amount, I will be notified by mail, telephone, and email of the remaining balance due.

I agree to pay that remaining balance in full within 30 days. If for any reason I cannot make scheduled payments, I must immediately contact The Exchange Dental Group to make acceptable arrangements. The Exchange Dental Group reserves the right to refer all unpaid accounts to collection agencies.

I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for services and materials not paid by my dental insurance company within 30 days of the submitted claim. To the extent permitted by law, I consent to your use and disclosure of my personal health information to be used for the sole purpose of collecting any payment due to The Exchange Dental Group.

Patient or Guarantor Signature

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Date:

To Our Valued Patients:

We appreciate and respect the trust you place in us to provide you with optimum dental care and services. As part of our commitment to excellent care and service, our staff will help you understand and make the most of your allowable dental insurance benefits.

It is important to understand that your benefit plan is an arrangement that involves you, your insurance carrier and your employer. Your benefits are based on the terms of the contract that your employer negotiated with the insurance company. Occasionally, services that are rendered may not be covered by your plan or there may be a deductible or co-payment that you or we are not aware of at the time of your visit.

In order for The Exchange Dental Group to run smoothly and continue to offer you high quality care, we respectfully request that you sign below to authorize our office to keep your signature and credit card on file. If, for any reason, you have a balance that is not covered by your insurance company or a balance that is owed due to a cancellation (as per our cancellation policy), the amount due will be charged to the credit card on file.

If you have any questions, please speak with a member of our Billing Department.

Thank you for your cooperation,

The Exchange Dental Group

Name:
Name on credit card:
Card Type: (please check one)
Card Number:
Exp. Date:
Security Code:
Signature:

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Date: