Arbor Creek Dental Form

Arbor Creek Dental

Dear Patient,

We would like to extend a warm welcome to you! Our goal is to provide you with the finest dental care possible in an environment that recognizes your individuality.

We strive to help you attain and maintain an excellent level of oral health for a lifetime. Your thoughts, opinions and concerns matter! So, feel free to ask any questions or bring up any issues or concerns that are important to you.

Feel free to fill out the forms and submit electronically OR Print, fill them out, and bring them completed to your intial visit. If you are filing insurance for your appointment, please bring your dental insurance card or have the Member ID and Group Number available. Our team is looking forward to meeting you soon.

Sincerely,

Jason Knag and Team

Our Three Commitments to You

A commitment between two people binds trust; I have three important commitments in my practice. I have put them in writing because I live by them, as does my team. I realize that the institution of these commitments may be different from what you may have been accustomed to in other dental practices; however, I believe that these commitments are necessary in building the trust that it takes for you and I to successfully work together.

Commitment to Treatment

Dental disease is nearly 100% preventable. Therefore, I believe that all treatment begun should be completed. I will deliver the best dental care that I am capable of delivering to you, and I ask that you care for your dental health on a daily basis to the best of your ability. Incomplete treatment leads to unnecessary problems and complications, such as the loss of teeth. It also leads to more advanced disease complications, such as the loss of teeth. It also leads to more advanced disease which unnecessarily adds to your cost and can lead to a breakdown in communication between the two of us. I understand that you likely want as little dentistry done in your lifetime as possible. Help yourself achieve that goal by following through with your dental plan.

Commitment to Appointment

I will reserve time especially for you in my schedule. I will give you my utmost attention and care and will rarely keep you waiting. An appointment scheduled in my office is a bond of trust that my team and I will be here to serve you and that you will be on time and prepared for your appointment.

Commitment to Financial Considerations

I believe that I have a responsibility to use my best professional care; skill and judgment in helping you achieve your dental health goals. As I have stated above, I believe dental disease is nearly 100% preventable. I will deliver the best dental care that I am capable of delivering to help attain your goals. It is up to you to make financial arrangements with my practice to pay for your services.

Full Name

First NameMiddle NameLast Name
Prefer to be called:
Sex:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail
Birthdate

MonthDayYear
Patients Social Security #:
How would you prefer to be contacted:
Status
Patients Employer:
Occupation:
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Patient is a Minor:
Parent's Name
Employer
Work Phone

Area CodePhone Number
Contact Number

Area CodePhone Number
Name Of School
Emergency Contact Information:
In the event of an emergency, who should we contact?
Relationship
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Whom may we thank for referring you?
How did you hear about us?

InternetLocationMailer/FlyerInsuranceYellow BookReferral

Insurance Information fill out as person carrying the insurance.
Name of Dental Insurance
Insurance Subscriber's name:
Insurance Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Social Security #:
ID #
Subscriber's Birth Date

MonthDayYear
Employer
Cell Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Group #:
Copy of insurance card

Upload a File

Cancelof

What is the reason for your visit today?
Date of last dental visit:

MonthDayYear
What was done the last dental visit?
Do you have any dental problems now?
Explain:
What would you change about your smile?
Are you interested in whitening your teeth?
Do you brush, floss, or use any dental aids?
Do you feel anxious or nervous about receiving dental treatment?

Do your gums bleed while brushing or flossing?*
Are your teeth sensitive to hot or cold liquids/foods?*
Are your teeth sensitive to sweet or sour foods/liquids?*
Do you feel any pain to any of your teeth?*
Do you have any sores or lumps in or near your mouth?*
Have you had any head, neck, or jaw injuries?*
Do you have frequent headaches?*
Do you clench or grind your teeth?*
Have you had any orthodontic work?*
Do you have any problems with your jaw? (clicking, pain, locking)*
Have you ever had a difficult extraction in the past?*
Have you ever had prolonged bleeding following an extraction?*
Have you ever had correct instruction for brushing and flossing?*
Have you ever had instructions on the care or your gums?*

Financial Policy
We thank you for selecting Arbor Creek Dental office for you dental needs. We will strive to provide the very best care for you. In order to do so, this sheet has been prepared to acquaint you with our financial policies.

Please be advised that for those patients or procedures without insurance coverage, payment is due in full as the services are rendered. For your convenience we accept cash, check, MasterCard, Visa, Discover Card and American Express. We also offer Care Credit Healthcare Financing applications or go online to carecredit.com for information.

Insurance Assignment and Management

In order to better serve your needs, our office contracts with Delta Dental KS, Guardian and Met Life Insurance Plans. We will be happy to assist you in filing any insurance however, it is up to each patient to know and understand the coverage, benefits, limitations, waiting periods, an exclusions of their own insurance plan. We will not be responsible if you do not follow the specific terms of your insurance agreement. Patients are responsible for paying their deductibles and co-pays at the time of service. Deductibles and co-pays are ESTIMATED for what benefits may be available. Please be advised that these estimates are just that, ESTIMATES to the best of our ability. We would be happy to pre-authorize any treatment at your request however; even pre-authorizations are not a guarantee of payment from your insurance company. Ultimately, you are responsible for any balances from unpaid claims.

We will be more than happy to file insurance claims for you in a prompt manner. We do not accept or file medical insurance. In order for us to file dental insurance on your behalf you must provide us with proper insurance information at the time of visit. If you are not able to provide this information or we are unable to verify your dental coverage, you will be required to pay in full at the time of service or you may choose to reschedule your appointment.

Please be advised that any balance on account that is over 60 days will be charged a finance charge of 18% annually (1.5% per month). Accounts that remain delinquent may be turned over for collection action with our attorney or collection agency.

BROKEN APPOINTMENTS: A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hour notice to avoid a $50.00 Cancellation Fee. (True emergencies are an exception)

Acknowledgement and Agreement

I certify that I have read, understand, accept and agree to abide, with all the terms of the financial policy above. I will not hold Arbor Creek Dental or any employee responsible for omissions I have made in the completion of information. If I provide insurance information to Arbor Creek Dental, I authorize Arbor Creek Dental to release information regarding my treatment for the purpose of filing for potential payment of insurance benefits and I grant assignment of any such proceeds to Arbor Creek Dental. I understand that Arbor Creek Dental is not allowed to give out any information to any person(s) unless I have them listed as follows:
Print Full Name
Signature

Clear

Composite Resin Fillings Consent Form

This is to inform you that our office strives to use only the best, most appropriate up-to-date materials for restorations. Because of this, we no longer use amalgam (silver fillings) in our practice and use only composite resin (tooth colored fillings) materials, porcelain and or gold.

Unfortunately, some insurance companies have not caught up to the current standards. They may give an “alternate benefit” for this procedure using an amalgam or metal filling rate. Therefore, it is in your best interest to know what your insurance policy covers as you will be responsible for any unpaid portion.

Should you have any questions or concerns regarding composite resin restorations, we would be happy to discuss it with you. Please sign below to acknowledge that you have read and understand the above information.
Print Name
Signature

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Medical Information Release Form HIPAA Release Form
Full Name

First NameLast Name
Date of Birth

MonthDayYear
I authorize the release of information including the diagnosis, records; examination rendered to me and claims informaiton. This information may be released to:

SpouseChildrenOther
Their Name
Messages - Please call

My HomeMy WorkMy Cell Number
If unable to reach me:

you may leave a detailed messageplease leave a message asking me to return your callOther
Best time to reach me start:

:HourMinutesAM/PM Option
Best time to reach me end:

:HourMinutesAM/PM Option
Type Full Name
Medical Information Release Form (HIPAA Release Form)

Clear

Dental Inquiry
Patient Name

First NameLast Name
Welcome to Arbor Creek Dental, this might be the most important dental visit you ever have.
We feel that helping you determine your present and future dental needs is the most important
service we offer. Although there are issues you have probably never thought of in detail, please
answer the following to your best ability.., Thank you!
What is your primary concern for the visit and what did you want to accomplish?
Have you ever had any unpleasant experiences associated with previous dental offices?
Have you ever been treated for gum disease?
What are your expectations of this office?
Treatment Recommendations or Treatment Options

We prefer to give you options based on how you would like to treat your dental health. We are here to make recommendations on how to achieve your goals.

The following questions help us determine what is important to you. Please rate on the following scale
from 1 to 10, with 10 being the MOST important.
How Healthy would you like your mouth to be?
How preventive or proactive would you like to be regarding your dental health?
How important are dental cosmetics to you? (example: whitening, straighter teeth, etc.)
Anything else you would like to mention so we may provide you with the BEST dental care possible?
Should be Empty: