We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire.
The better we communicate, the better we can care for you. If you have any questions or need assistance, please
ask us - we will be happy to help.
Do you have or have ever had any of the following? Please check those that apply:
* This condition may require antibiotic premedication for certain dental procedures.
Do you have any health problems that were not listed above or need further clarifications?
Are you now under the care of a physician?
Have you been admitted to a hospital or needed emergency care during the past two years?
Are you taking any medications or herbals?
Are you allergic to any medications or substances?
If yes, please check box below:
To the best of my knowledge, all of the preceding answers are correct.
If I have any changes in my health status or if my medications change, I will inform the dentist and the staff at the next appointment without fail.
x You will sign here when you get to the practice
We believe that each patient deserves to know what their current level of dental health is, how they got there, and what treatment options are available to help them reach the level of health that they deserve.
This begins with a careful diagno-sis and personalized treatment plan. We will perform a comprehensive oral examination of your teeth, gums, jaw joints, bite and soft tissues.
We will also take the appropriate x-rays, and when beneficial we may take additional diagnostic records such as photographs or casts of your teeth to further evaluate areas of concern.
Once all your records have been completed they will be carefully evaluated to determine your current level of dental health and how you got there.
We will review our findings with you and discuss your treatment options.
A personalized treatment plan will then be developed to help you achieve the goals we set together.
Please help us better understand your dental health needs and goals by answering the following questions. (check the best answer):
Have you had a full mouth set of x-rays (other than routine cavity detecting x-rays) within the last 3 years?
Fear of going to the dentist.
I think my present state of dental health is
APPOINTMENTS
We value your time so you can expect us to see you at the appointed time and to keep your time spent in our office as short as possible.
In return, when you make an appointment with us please be on time since we have reserved our time just for you.
Please make every effort not to change your scheduled appointment.
If you must change an appointment, please provide us at least 2 working days advanced notification so that we may use our time to accommodate other pa-tients.
Broken and missed appointments create scheduling problems for other patients and our practice. We value your time, please value ours.
FINANCIAL POLICY
Unless another financial option is PRE-ARRANGED, payment in full is due the day of treatment, or on pre-op vis-its for sedation appointments.
Should a patient have dental insurance with assignment to Gregg Family Dentistry, the estimated patient portion will be the amount due.
Insurance payments without assignment will be sent to the insured with payment due in full.
Payment Options
For your convenience we accept Cash, Check, Visa, MasterCard & Discover.
For Patients with Dental Insurance
Dental insurance plans often pay less than the actual fee for service, therefore the patient or Guarantor is the re-sponsible party for all dental services provided.
Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs.
Your dental benefits and how they relate to your specific needs will be explained to you after the treatment plan is presented.
AUTHORIZATION AND CONSENT
General Consent to Treatment
I agree and consent to a dental examination by Gregg Family Dentistry and his staff.
I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.
Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed.
Release of Information
I authorize Gregg Family Dentistry to release any information regarding my dental/medical history, diagnosis or treatment to third party payors and/or other health professionals.
Assignment of Insurance Benefits
I authorize and request my insurance company to pay my benefits directly to Gregg Family Dentistry .
Photography Release
I authorize Gregg Family Dentistry to take photographs of me to help me better understand my current dental condition and possible treatment options.
x You will sign here when you get to the practice
