Form

Smile Visit Questionnaire

First Name

Last Name

Date Of Birth

What is the reason for your visit?

Please describe your Chief Complaint

Are there any changes to your Medical History since your last visit?

If yes, please explain.

Are you interested in the following:

Financial Policy

Payment is due at the time service is provided. If you have insurance, the patient portion for dental service(s) is estimated and may be subject to adjustment when the dental service(s) claim(s) are adjudicated by the insurance company. The claims we submit to insurance companies indicate that you have assigned those benefits to All Care General Dentistry. However, if you are paid by the insurance company instead, you then become responsible for the total account balance and payment would be expected immediately. You as a patient are always responsible for any charges that are not covered by your insurance.

Appointment Cancellation Policy
Appointments cancelled without 48 hours notice and missed appointments will be charged a fee of $75. As a courtesy to others, we reserve the right to reschedule your appointment if you are more than 15 minutes late. This will count as a missed appointment and you will be charged a fee of $75.

Patient/Parent/Legal Guardian Signature

Date