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Welcome!Patient Name

Putient Information

First

Home Phone#

Address

Cell # Office#

ApUSuite#

City State Zip

email Birthdate Sex: UMale nFemale

Social Security # lSingle !Married nMinor (under 18)

Ilnsurance list nwebsite !Phone BookReferred by:

Fnvrl=v &CoSMETICDENTISTRY

Employer/Occupation

Employer/School

Occupation

Employer'sAddress

Flow Long?.

In Case of Emergency

Whom do we contact?

Relation

Home# Cell#

Who is you medicaldoctor?Doctor's Phone #

Responsible PartyPerson ultimately responsible for the account Relation

Address City State_ZipSS# D.O.B. Drivers License #

Primurv Dental Ins urance

lnsured Person'sName

Relation to Patient D.O.B.

lnsured'sAddress Apt#

City State zip

lnsured's SS#lnsured'sEmployer

lnsurance Co.

Group or Plan#

lns. Co.'s Eligibility Verification #

Additianal Dentul Ins urance

Insured Person'sName

Relation to Patient D.O.B

lnsured'sAddress Apt#

City State Zip

lnsured's SS#lnsured'sEmployer

lnsurance Co.

Group or Plan#

Ins. Co.'s Eligibility Verification #.

Dentul InformationReason for Today's visit?

bate of: last dental exam

Do your teeth or jaws hurt when you eat or drink?

Are there any dark or old fillings that you'd like to

last cleaning

Do your gums bleed when you brush?

Which ones?

Are you in pain?

last X-rays

replace?

Do you have any broken teeth or fillings? Would you like to whiten your smile?

Former Dentist What type of toothbrush do you use? I Manual I Electric

Medicsl InformationDo you now have or have you ever had any of the following diseases or medical conditions?

YES NO

u Ll Anemra! tr Arthritistr tr Artificial Heart valveu ! ArtificialJointsu u Astnmatr tr Back Problemsn U Blood diseasetr tr Cancer! tr Chemical Dependencytr tr Circulatory Problemsn n Cortisone Treatments! tr Cough, persrbfenf[ ! Osteoporosis

YES NO

I1 U UIADEIES

tr D Epilepsytr ! Faintingtr tr Glaucoma! ! Headache/severetr tr Heart Murmurtr tr Heart Problems/ chest pain

n tr Hepatitistr tr High Blood Pressure! tr HIV+/AIDStr n Kidney Diseasetr U Liver diseasetr ! MitralValve Prolapse

YES NO

tr tr PacemakerI U Psychiatric CareU tr Radiation Treatmenttr tr Respiratory Disease[ tr Rheumatic Fevertr tr scarlet FeverU ! Short of Breath! tr Sinus problems[ tr Stroketr n Swollen Anklestr n Thyroid Problemstr D Ulcerstj tr Venereal Disease

I No DescribeAre you currently under a doctor's care for any medical condition? [ Yes

Are you allergic to any of the following? D Penicillin/Antibiotics tr Latex !Aspirin nDentalAnesthetics

Do you smoke? lYes nNo Cigarettes /day For how long?

Have you had any surgeries or hospitalizations in the last two years?

Have you ever taken any of the group of drugs known as Phen-fen and/or Redux? [Yes lNo

Women: Are you pregnant? lyes INo: Nursing? nYes nNo: Taking Birth Control Pills? lYes DNo

MedicationsList any medications, and the doses of those medications, that you are currently taking. Please include:

Prescribed, Over-the-counter, Herbal supplements, Aspirin, Pain Medicine, Diet Pills, Sleep Aids, Birth control Pills

AuthorizationsI have read and understand each question about my medical conditions and medications. I will inform the Dentist or Hygienistif there are ever any changes in my health and/or medications.

I authorize my insurance company to pay the dentist all insurance benefits othenvise payable to me for services rendered. I

authorize the use of my signature on all insurance submissions. I authorize the dentist to use my health and dental careinformation and to disclose such information to the insurance companies and their agents for the purpose of obtaining payment

for services and for determining insurance benefits payable for related services.

I consent to the dental procedures, medications, and anesthetics required for treatment of the above named patient. I acknow-ledge that I have been informed of the risks and consequences of the treatment proposed and do authorize Dr. Bialick and his

staff to proceed with treatment.

Signature Date

RIqHARDE!IALICKGENERAL &cosIt|ETlCDENTISTRY

FINANCIAL POLICY

At the dental office of Richard Bialick PhD, DDS, We are

committed to providing you with the best possible dental care. In order to

achieve these goals we need your assistance and your understanding of ourpayment policy.

INSURANCEYour insurance is a contract between you, your employer, and the insurance co.

We are not a party to that contract. Not all dental services are covered benefits in all contracts.

Some insurance companies arbitrarily select certain services that they will limit or not cover at

all. Many require a waiting period before they will cover some dental procedures. Dr. Bialick's

treatment plans and services are based on your dental needs and not on your dental coverage'

You, the dental patient, are responsible for your dental charges in their entirety including any

procedures that your insurance company refuses to cover.

As a courtesy to our patients, at the time of service, we will bill your insurance co. one

time. You are responsible for providing accurate insurance co. information, group numbers, and

social security numbers. There is a $25.00 processing fee if claims need to be re-submitted

because of outdated or inaccurate dental insurance information.

PAYMENT DUEPayments for service are due at the time rendered. This includes all co-payments,

deductibles and non-covered procedures. We accept cash, check, VISA, MasterCard, and

Discover card.

FINANCE CHARGES, RETURNED CHECKS, COLLECTIONSIf a check issued by you is returned by the bank, you will be charged S25.00 in addition

to the amount shown on the check. Any account balance which is more than 30 days past due

is subject to a finance charge. A finance charge of 1.5"/" (annual rate of 18%) will be

applied to your balance. In the case of default of payment, you will be charged any interest on

the balance due, together with collection and attorney fees incurred to effect collection of your

account or future outstanding accounts.

MISSED APPOINTMENTSIf you are unable to keep your appointment, please call at least24 hours in advance so

that someone else may have an opportunity to see the doctor or hygienist at the time you reserved.

There wilt be a $50.00 charge added to your account if you have two (2) "no show" orappointments that are broken without 24 hours notice to our office. On procedures

scheduled for two hours or more (large procedures), a non-refundable security deposit of $75.00

will be required to hold the time for you. These large appointment slots require 48 hours

advanced notice of cancellation. This deposit will be credited to your account when you keep the

appointment.

I have read the financial policy for the dental office of Richard Bialick PhD'DDS. I understand, and agree to abide by, the policy described under the headings

of Insurance, Payment Due, Finance Charges, and Missed Appointments.

Signature Date