WELCOME! Thank you for choosing our office. We strive to provide you with the most gentle, quality care possible. If you have any questions, or we can help you in any way, please feel free to ask. Patient Information (Confidential): First Name Last Name (If child, parent/guardian name) Birth date Sex Male Female Age Soc. Sec. # Home Address City State Zip Home Phone Work Phone Cell Phone Driver's License # Email Employer Occupation How long there? May we call? Employer Address City State Zip Spouse's Name (Or other parent/guardian) Soc. Sec. # Spouse's Employer Occupation How long there? May We Call? Spouse's Employer Address City State Zip If patient is a student: Name of School or College City/State Full or Part Time? How did you hear about our practice? Primary Insurance: Name of Insured Birth date Relationship to patient Address (if different from patient) Dental Insurace Co. Phone Soc. Sec. # Subscriber ID # Group, Contract or Local or Union # Additional Insurance: Name of Insured Birth date Relationship to patient Address (if different from patient) Dental Insurace Co. Phone Soc. Sec. # Subscriber ID # Group, Contract or Local or Union # Copayments: To accept insurance, we now debit copayments automatically to your credit card. If you would like us to accept your Insurance, please provide credit card information: Credit Card Debit Card Master Card Visa American Express Name of Card Account # Expiration Date In case of emergency: Name and City of primary care physician Someone we may contact, not living with you Phone #'s (home, work, cell) Authorization: I authorize my insurance company to make payments directly to the dental office for benefits otherwise payable to me. I authorize release of my records to third party payers, other healthcare professionals or operations, or other entities as deemed necessary by this office. I authorize use of this signature for all insurance submissions. I understand that I am responsible for all charges whether or not they are covered by insurance, as well as any additional collection costs if this office determines they are necessary. I authorize this office to charge my credit card for any unpaid balances, including those after insurance payment. I understand that in certain circumstances, my credit report may be requested. I have reviewed the information on this form, and it is accurate to the best of my knowledge. I have received a copy of this office's Notice of Privacy Practices. Signature Date   Patient or Responsible Party   Dental History Patient Name Age Date Reason for seeking care today: Exam Cleaning Specific Problem Please check all that apply: Toothache Broken filling or tooth Sensitivity to: Cold Hot Sweets Chewing Food catches Loose teeth Floss breaks easily or hurts Bite or teeth have shifted Often bite cheeks Frequent dry mouth Concerned about breath Unhappy with previous dental work Gums bleed Gums tender Growths, sores Cold sores, fever blisters Cracked, chapped lips Bad taste in mouth Sinus problems Mouth breathe - Difficulty breathing through nose Dry or strained eyes Shoulder, neck or headaches Clench or grind teeth Jaw joint pain Clicking or popping of joint Unable to open mouth wide Jaw gets tired easily Hold things between teeth (Pipe, pencil, nails, pins) Bite fingernails Unusual habits with teeth Wore braces Previous gum treatment Previous bite treatment Would you like whiter teeth? On a scale from 1 to 10, how would you rate your smile (with ten your smile is perfect.) Please rate 1-10 how anxious you are about dental treatment (1 = totally relaxed) Have you ever had a bad experience at the dentist? (Treatment? Staff? Billing?) Why did you leave your previous dentist? Did your parents have difficulties with their teeth or dental treatments? Medical History Physician's Name City Phone Have you been hospitalized for any reason? Please describe: Are you taking any medications or drugs (including nutritional supplements?) Please list: (Continue on back of form if needed) Are you allergic to penicillin, aspirin, local anesthetics, latex, sulfa, codeine, other? Do you smoke? How much/day? (Yes) / (No) Pregnant? Due date Are you nursing? Are you seeing a physician now or planning to see one for any reason? Please explain: Please check all that apply: Previous injury to head or neck Diabetes Sickle cell Shortness of breath Heart problem HIV or AIDS Digestive problem, ulcer Snoring, sleep apnea Heart Attack Glaucoma Thyroid disease Seizures/Epilepsy Angina, chest pain Liver problem, jaundice Easily winded Fainting or dizzy Heart murmur Cirrhosis, Hepatitis Bleed or bruise easily Unexplained weight loss Scarlet, Rheumatic fever Cancer Stroke Chewing tobacco Mitral valve prolapse Radiation, Chemotherapy Parkinson's Drug or alcohol addiction Irregular heartbeat Respiratory problem Alzheimer's 2 or more social drinks/day High or low blood pressure Bloody, persistent cough Back problem Anxiety or nervous disorder Pacemaker Asthma, Emphysema Hives, rash, Herpes Insomnia Artificial joint Tuberculosis Prolonged bleeding Received any donor organs Arthritis Anemia Kidney problem Please list any other illnesses or medical condition not checked above: Please indicate if you would prefer to speak privately with the dentist about a medical issue: Yes No I will inform this office of any changes in my health status. I understand that dental treatment and local anesthesia entail risks such as bleeding, infection, nerve damage, or fracture of teeth or bone. I certify that the above information is complete and accurate to the best of my knowledge. Patient Signature (parent or guardian) Date Dentist's Signature _____________________ Date _____________________   Written Financial Policy Thank you for choosing Grosse Pointe Signature Smiles. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable as possible for our patients by offering payment options. Payment Options: -Cash, check or credit cards such as Visa and Mastercard -Payment Plans from CareCredit Allow you to pay overtime some plans have NO interest Convenient, low monthly payment plans No annual fees or pre-payment penalties -Discount to help you save: We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion for treatment plans of $2000 or more. (If you have insurance, we will still process your claim having the benefits go directly to you.) Please Note: Requited Deposit: For larger, more comprehensive treatment plans of $500 or more, a 10% deposit is required to to secure your initial treatment. For plans requiring multiple appointments alternative payment arrangements may be provided. Missed Appointment: A fee of $75 is charge for patient to mess or cancel more than one time in a calendar year without 48-hour notice. Overdue Accounts: A charge of 10% interest on the balance for past accounts of 30 days or more. Returned Checks: A charge of $50 for returned checks. Dental Insurance: We are happy to work with your carrier to maximize your benefit and process your insurance for payment and in doing so we request your estimated time payment be paid when servers are delivered. However, your contract is between your employer and your carrier and we have no control over their decisions. Occasionally benefits are limited and payments are delayed. You're responsible for all financial cost a treatment and if your carrier does not pay in full within 90 days of service we will bill you for the outstanding balance. VIP Checkout: You don't have to wait after your appointment! If you leave a credit card on file to cover any additional fees that may come do once your insurance payment is received we will automatically credit or debit or credit card. If you have any questions please do not hesitate to ask, we are here to help you get the dentistry you deserve. Date Patient Name (please print) Patient, Parent or Guardian Signature   ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM You may refuse to sign this acknowledgement but, in refusing we will not be allowed to process your insurance claims. Date: The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Grosse Pointe Signature Smiles. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS IN THE FUTURE. Please print your name Legal Representative Description of Authority Please sign your name PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR DENTAL INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient's record Name: Relationship: Name: Relationship: Name: Relationship: I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY DENTAL APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation U. S. Mail / Postcard Any of the above I AUTHORIZE INFORMATION ABOUT MY DENTAL HEALTH BE CONVEYED VIA: Message on Cell Phone Message on Home Phone Message on Work Phone Email Message U. S. Mail / Postcard Any of the above I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS or NEW DENTAL INFO VIA: Phone Message Text Message Email U. S. Mail / Postcard Any of the above None of the above Office Use Only As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment ___________________ I could not communicate with the patient ___________________ The patient refused to sign ___________________ The patient was unable to sign because ___________________ Other (please describe) ___________________ _____________________________ Signature of Privacy Officer Please enter code above in the field below.