CBD Dental Care Inc.              316 Baronne St .               N.O. LA 70112                     525 - 9990  

PATIENT INFORMATION HEALTH QUESTIONNAIRE                   Date_______________ 

SOCIAL SECURITY #__________________________________DL#_____________________________

Name______________________Birthdate__________Home #______________  Cell # ______________

Address_________________________________ Apt # _________City________________ Zip_________  

Email address: _________________________________

Circle Appropriate:  Minor         Single         Married         Divorced            Widowed           Separated

Patient’s or Parent’s Employer ______________________________ Work #_____________ Ext #  _____

Occupation___________________________________

Business Address____________________________City__________________State_________Zip_________  

Spouse or Parent’s Name ____________________Employer _________________Work #_____________

                                                                                                                       Ext #  ________

If a full-time student, Name of School/College __________________________ Degree In?_____________  

Whom May We Thank for Referring You?    

 ˛  A Friend_________________________   ˛ Yellow Pages         ˛ Newspaper     ˛ Radio        ˛ Website  

Person to Contact in Case of Emergency ______________________________Phone #_________________  

RESPONSIBLE PARTY (if other than you or if patient is a child)                                                                                                  

Responsible Person for this Account ____________________________ relationship to you_______________

Address _______________________________________________________Home Phone________________

Driver’s License #_____________________________DOB ____________________SS #_________________

Employer ______________________________________________________Work Phone________________  

 

INSURANCE INFORMATION                                                               

Name of Insured____________________________________ Relationship to Patient___________________  

DOB ______________________SS#_____________________ Date Employed _______________________  

Name of Employer ____________________________________________Work Phone #________________  

Address of Employer _________________________________City____________ State _____Zip_______  

Insurance Company _________________________________Group #_________ Ins Co. #_______________  

Ins. Co. Address _______________________________City _____________State _________Zip__________  

DO YOU HAVE ADDITIONAL DENTAL INSURANCE? __Yes __ No   IF YES, COMPLETE THE FOLLOWING:

Name of Insured ______________________________________Relationship to Patient___________________

DOB __________________________SS #____________________________Date Employed ______________

Name of Employer _______________________________________________Work Phone #_______________

Address of Employer _________________________________City ____________State _____Zip__________

Insurance Company ____________________________________Group #__________Ins Co #_____________

Ins. Co. Address ______________________________________City _____________State ____Zip_________

DENTAL HISTORY

Reason for Today’s Visit ________________________________Former Dentist__________________________

Date of last dental care _________________________________Date of last x-rays_______________________  

Check if you have had problems with any of the following:

____Bad Breath ____Grinding teeth ____Sensitivity to hot
____Bleeding gums                      ____Loose teeth or broken fillings ____Sensitivity to sweets
____Clicking or popping jaw ____Periodontal treatment ____Sensitivity when biting
____Food collection between teeth ____Sensitivity to cold ____Sores/growths in mouth

Are you interested in WHITER TEETH? ______        Are you interested in FRESH BREATH products? _____  

Are you interested in IMPLANTS? ______               Are you interested in ORTHODONTICS/BRACES? _____  

Are you interested in DECREASED SENSITIVITY? _______

How often do you floss? ______________________  How often do you brush?__________________  

MEDICAL HISTORY

Physician’s Name ___________________________Date of last visit____________________________________ 

Have you had any operations or serious injury?     ˛ Yes        ˛ No  
If yes, please describe_________________________________________________________________________  

Women Only:  
Are you pregnant? ___ Yes ___ No         Nursing? ___Yes ___No      Taking birth control pills? ___Yes ___No  

ALL PATIENTS:  Check if you have or have had any of the following:  

____AIDS                           ____Cough, Persistent ____Hemophilia                       ____Scarlet Fever
____Anemia                        ____Diabetes                 ____Hepatitis A B C ____Sexually 
____Arthritis, Rheumatism  ____Emphysema             ____High Blood Pressure          Transmitted Disease
____Artificial Joints ____Epilepsy                      ____Low Blood Pressure ____Shortness of Breath
____Asthma                     ____Fainting                        ____HIV Positive ____Skin Rash
____Back Problems ____Glaucoma                    ____Jaw Pain  ____Stroke
____Blood Disease ____Headaches ____Kidney Disease  ____Swelling of 
____Cancer                     ____Heart Problems            ____Liver Disease         Feet or Ankles
____ Radiation Treatment- Describe:
____ Nervous Problems             ____Thyroid Problem   ____Chemotherapy              ____Heart Murmur           
____Psychiatric Care                ____Tobacco Habit          ____Chemical Dependency ____ Mitral Valve Prolapse   
____Pacemaker                        ____Recent Weight Loss  ____Tuberculosis    ____Circulatory Problems
____Respiratory Disease  ____Ulcer ____Cortisone Treatments  ____Artificial Heart Valve
____Rheumatic Fever ____ None of the above  

 

Are you under any medical treatment now?          NO       YES (please describe) :  ______________________________________________________________________    

ALLERGIES MEDICATIONS
Are you allergic to or have you had any reactions to any of the following?: List medications you are currently taking:
____Local Anesthetics ____Sedatives   ___________________________________
____Iodine ____Sulfa Drugs ___________________________________  
____Barbiturates ____Penicillin ___________________________________                                 
____Aspirin ____ Other Antibiotics (describe) ___________________________________                            

AUTHORIZATION  
I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered.  *  I authorize the use of this signature on all insurance submissions.  *  I authorize the dentist to release all information necessary to secure the payment of benefits.  *   I understand that I am financially responsible for all charges whether or not paid by insurance.  *I understand all fees associated with collecting my balance will be my responsibility.

 Signature__________________________________________________Date________________________

 

PAYMENT/INSURANCE AGREEMENT:

     We, the Doctors and Staff, welcome you to our office.  We want you to be comfortable and satisfied with our office and services and if there is anything we need to do to make it so, we will welcome your input.  

The following are a few of our office policies that we feel need to be mentioned: 

            Our office schedule is designed to allow us to operate at maximum efficiency while keeping your wait to a minimum, preferably with no wait at all.  The worst disruption to the schedule comes when a patient fails to show up for their appointment.

  As we try not to over book our schedule, this “NO SHOW” literally leaves us with nothing to do.  Therefore, there will be a fee of up to $40.00 per hour.

 We also request, for the same reasons mentioned above, a 48-hours notice to cancel an appointment.  There will be a charge for appointments cancelled without 48-hours notice

Please remember the appointment time is reserved for you. We will attempt to remind you of your reservation by calling the phone numbers you provide.  We do this as a courtesy and we will make every effort to confirm the appointment.  However, it is the patients’ responsibility to keep the appointment even if we are unable to contact you.

 Payments are due in full on the day of service.  We offer several payment methods such as cash, local personal checks, most major credit cards and extended payment plans.  Arrangements for extended payment plans must be made before any service will be started.  There is a fee of $25.00 for all returned checks. NSF checks will be sought after to the full extent of the law.

             It is the patients’ responsibility for any unpaid balances regardless of your insurance coverage.  Insurance companies are numerous with varied benefits and various levels of coverage.   Your policy is a contract between you and your insurance company.  We will attempt to estimate your portion (co-payment) but please remember that this is only an estimate and the actual amount will vary depending on your deductible being met and whether your insurer accepts our fees as “Usual and Customary (UCR)”.  Remember, it is your insurer who decides what the “Usual and Customary” fee is and it is in their best interest to keep the UCR low. 

Our office will almost always do a metal-free, tooth-colored filling (resin). Most insurance companies will only pay for the lesser metal fillings (amalgam). If you would like a metal filling, please tell us each time before we do our procedure.  The difference in cost between these filling materials can range from $10 to $30 and we will either collect the difference at the time of service or after your insurance has paid.

 If you have multiple plans, we will file them all for you as a courtesy, but payment will be expected at the time of service based on your PRIMARY PLAN benefits.  Any credit due you will be issued promptly at your request once secondary claim has cleared.

If you have a DISCOUNTED FEE PLAN, payment in full is due the day services are rendered, otherwise you will be charged and responsible for the full fee.   

            If your coverage lapses or if you no longer participate as a member of a plan, you will be charged our regular fees. If after all claims are paid and there is a balance or if there is a balance for any other reason, you will have 30 days to pay the amount due.  If your account is not paid in the allotted time, it will be turned over to our Collection Agency.  Please note that in addition to your balance, any fees associated with collecting your balance will be your responsibility.

 I have read, understand and agree to the office policies mentioned above.  

           Signature__________________________________________________Date________________________

                   (If patient is a minor parent’s signature is needed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TREATMENT RECORD 

 

Name______________________________________Birthdate________________Sex___________

 

DATE

TREATMENT NOTES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 V-CILLIN K             AMOXICILLIN                ERYTHROMYCIN                     TETRACYCLINE  

PERCOCET           VICODIN          MOTRIN           GEL-KAM         KENALOG         PERIDEX 

           CLINDAMYCIN         DOXYCYCLINE