Form

Existing Patient Update

Patient's First Name

Patient's Last Name

Sex

DOB

Name / Relationship to Patient

POA Full Name & Relationship to Patient

POA Street Address

POA City, State, Zip

POA Cell Phone

POA Home Phone

POA Email

Fiduciary Company

Fiduciary Street Address, City, State, Zip

Fiduciary Case Manager

Fiduciary Phone

I am stating that I am self responsible and I authorize Smiels by Delivery to contact the person I am appointing as my emergencey contact to verify that status of me being self responsible.

Emergency Contact Person & Relationship to Patient

Emergency Contact Phone

Emergency Contact Email

The HIPAA recommended form of conveying emailed patient information is via encrypted email, which our office can help you set up with a user name an password. However, you can choose to convey information with our office via conventional email. Please choose which form of email you would prefer:

Name of Physician

Physician's Phone

Are you being treated by a physician?

What are you being treated for?

Have you been hospitalized in the last 5 years?

Approximate Month/Year of Hospitilization:

What were you hospitalized for?

Name of Pharmacy

Pharmacy Phone

Are you currently taking medications?

Medication List

File Uploader

Upload or drag files here

Do you have any allergies to medications?

What medication allergies?

If you are taking a PRESCRIPTION BLOOD THINNER, (such as Coumadin, Eliquis, Plavix, Pradaxa or Xarelto), we will need to contact your physician to get medical orders for their instructions prior to dental extractions.

Are you currently taking a PRESCRIPTION BLOOD THINNER? (not OTC aspirin)

If you have EVER TAKEN A BISPHOSPHONATE medication, (such as Actonel, Boniva, Fosamax, Reclast or Zometa), for osteoporosis or Paget's disease, we will need to consult with your physician to determine if you will need to be referred to an oral surgeon for dental extractions.

Have you EVER taken BISPHOSPHONATES?

When did you start and finish bisphosphonate use?

Have you been diagnosised with Alzheimer's?

What stage of Alzheimer's?

Do you have an ARTIFICIAL JOINT?

If so, what joint and when was it placed?

Have you ever been instructed to PREMEDICATE WITH AN ANTIBIOTIC PRIOR TO A DENTAL APPOINTMENT FOR A NON-INFECTION CONDITION?

What was the non-infection condition? (ie: artifical joint, artificial heart valve, etc)

Have you had an ARTIFICIAL HEART VALVE REPLACEMENT?

Month/year of heart valve replacement?

Do you currently have a CENTRAL VENOUS CATHETER (CVC)?

When was CVC placed and why was it placed?

Have you had a stroke?

Month/year of stroke?

Have you had a heart attack?

Month/year of heart attack?

AIDS/HIV

Cancer

Diabetes

COPD

Parkinson's

Heart Disease

Oxygen Use

Trach in Place

Organ Transplant Recipient

Head/Neck Radiation

Current Diaylsis

High Blood Pressure

Low Blood Pressure

Congestive Heart Failure

Sedative Request

At Smiles by Delivery, we strive to provide the best and most comprehensive dental care to our patients. We make every effort to keep down the cost of your dental care. One way to keep cost down is to not have a billing department.

By signing below, I understand and agree that:

A cancelation fee of $99 may be charged for patients who miss or cancel an appointment without 24 hour notice. If a patient cancels three appointments, the patient may be dismissed from our practice and asked to find another dentist.
Payment is due at time of service. If the financially responsible person is not present at the appointment, payment will be due prior to the appointment.
A returned check fee of $50 will be applied to my account for each returned check payment.

Payment Options:

Check
Visa, Mastercard American Express or Discover
Credit card payment can be made over the phone or on our secure patient portal, found on our website, www.SmilesByDelivery.com
CareCredit Healthcare Credit Card
Convenient monthly payment options from CareCredit Healthcare Credit Card. If a payment plan is needed, we suggest applying for CareCredit Healthcare Credit Card. CareCredit can be contacted by:
Phone: 800-365-8295
Online: www.CareCredit.com
Our Website: www.SmilesByDelivery.com

THINK PREVENTION: I have been presented an option to register with the Think Prevention, the 12 month saving program, and that all details of the plan can be found on the Join Our Membership Registration Link at SmilesByDelivery.com. I understand that if I join Think Prevention, then cancel after the start of the program for any reason, any unused cleaning appointments will be donated to low-income seniors in need of dental care, as the program is non-refundable. I also understand that any unused cleaning appointments will be forfeited 12 months after the start of the program.

Dental Insurance: By signing below, I authorize Smiles by Delivery to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim. I also authorize Smiles by Delivery to appeal on denied claims, on my behalf. It is my responsibility to verify whether my insurance is an out-of-network or in-network plan and if my insurance is active. I understand that Smiles by Delivery can assist me in verifying this information.

PPO Out-of-Network Plans: Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by Smiles by Delivery, not an obligation. I understand that if Smiles by Delivery is out-of-network with my dental insurance plan, my insurance is not accepted as a form of payment.
In-Network Plans: If Smiles by Delivery is in network with my dental insurance, I authorize my insurance benefit to be directed to Smiles by Delivery. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.

Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total.

Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics.

A submission to my insurance provider may be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.

As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. Smiles by Delivery will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments can not be guaranteed because they may need to be modified as needed to accomplish the best result possible.

I have read, understand and agree to the above financial policy for payment of professional fees. I understand that I am ultimately responsible for all fees for services rendered to me and/or my family.

*By signing below, I also consent to any recommended x-rays, teledentistry exams, clinical exams, cleanings (prophy or fullmouth debridement), and fluoride treatments. I understand that a licensed dental hygienist or licensed affiliated practice dental hygienist will be providing the dental hygiene services. Dental hygiene care alone does not take the place of a dental examination or complete dental care. The teledentistry exams, clinical exams, dental diagnosis, treatment plans and restorative treatments are provided by licensed dentists, which may follow the appointment with the hygienist. I also understand that it is Smiles by Delivery's policy that active patients must have their next hygiene appointment scheduled.

By signing below, I certify that all of the above information is true to the best of my knowledge. I am choosing Smiles by Delivery to be my primary dental provider for my preventative and restorative dental needs. Smiles by Delivery will replace any previous dental provider I may have had. I request that any appointments scheduled with my previous provider be canceled, as of the date of this signed registration. I also request that my dental records be faxed to Smiles by Delivery at: 623-584-4750. I understand that I am required to complete Smiles by Delivery's update form on a yearly basis. I also understand that it is my responsiblity to request an update form prior to any dental appointment, if there are any changes, including but not limited to medical changes, status changes regarding responsibility and care, or any other account changes.
I understand that I must submit authorization to Smiles by Delivery for Smiles by Delivery to disclose any of my clinical information or information of my care to anyone other than of my medical provider, support team members and any legally appointed persons. The information shared with my medical provider and support team will be specifically clinical care information, excluding financial information, unless otherwise requested in writing by the responsible party.

Responsible Party Full Name & Relationship to Patient

Patient's Full Name

Responsible Party Signature

Date

rev1/5/2023