Health History & Registration

Patient Information

Patient's Name
Sex

Insurance Information

Do you have insurance?
(Select One)
Select Method of Payment:

My signature authorizes release of my medical information and x-rays; and authorizes payment directly to Goodman Road Dental. upon completion of treatment.

Office Policy

Insurance

I UNDERSTAND THAT GOODMAN ROAD DENTAL IS AN OUT OF NETWORK PROVIDER AND THAT I AM RESPONSIBLE FOR MY INSURANCE DEDUCTIBLE AND CO-PAYS, SET OUT BY MY INSURANCE COMPANY, ON THE DAY SERVICES ARE RENDERED. I also understand that my dental insurance is a contract between me and the insurance company, not between the insurance company and Goodman Road Dental. I UNDERSTAND THAT AS A COURTESY TO ME, GOODMAN ROAD DENTAL OFFICE WILL FILE MY INSURANCE, HOWEVER I AM STILL RESPONSIBLE FOR ALL DENTAL CHARGES. If the insurance company has not paid their portion within 30 days of being properly billed, as mandated by the insurance Commissioner of the State of Tennessee, I understand that the balance will become due and payable from me.

Delinquent Accounts

I understand that payment is due at the time services are rendered unless payment arrangements have been made and approved in advance. All unpaid balances will be subject to a finance charge after 90 days of 1.5% per month, which is an annual percentage rate of 14%. In the event we are forced to submit a delinquent account to a collection agency, I agree to reimburse any fees of any collection agency, which will be 33% of the debt, and all costs, and expenses, including reasonably attorney's fees we incur in such collection efforts, which will be added at the time the account is sent for collection.

Failed Appointment Charge

I understand that as a courtesy to me, I will either be called, emailed or texted the day before the appointment to confirm. We are reserving that time exclusively for you, if for any reason you can no longer make your appointment please call within 24 hours to cancel or reschedule. Otherwise, you will be charged for a failed appointment fee. If I fail my appointment without giving 24 hrs notice a $25 FAILED APPOINTMENT CHARGE will be added to my account. If the appointment was for two hrs, there will be a charge for $50 added to my account.

Returned Checks

All returned checks are subject to a $50 service fee. Any returned check must be resolved before any future appointments can be arranged.

I understand that responsibility for payment for dental services provided for my dependent or myself is MINE, due and payable at the time services are rendered.

Medical & Dental History

It is important that I know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.
Medical History
Yes No
Do you use tobacco?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Do you take, or have you taken, Phen-Fen or Redux?
Do you take, or have you taken fosmax, actone, boniva, or esvista for osteoporosis?
Women
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Dental History
Yes No
Are you having PROBLEMS now?
Are your teeth sensitive to hot, cold, sweets, or pressure?
Do you wear dentures or partials?
Would you like to know more about
PERMANENT REPLACEMENTS?
Are you APPREHENSIVE about dental treatment?
Have you had any PERIODONTAL (GUM) treatments?
Do your gums BLEED, or feel TENDER or IRRITATED?
Are you aware of GRINDING or CLENCHING your teeth?
Do you have HEADACHES, EARACHES, or NECK PAIN?
How do you feel about your teeth?
Are you satisfied with your teeth?
Do you have discolored teeth that bother you?
Are you unhappy with the appearance of your teeth?
Would you like your smile to look better or different?
Are you interested in whitening your smile?
Yes No
Do you snore OR have you ever been told you snore?
Have you been diagnosed with sleep apnea?
Do you wear a C-PAP or have you in the past or have you been told to?
Have you had a sleep study or been told to get a sleep study?
Have you ever had any serious illness not listed above?
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