First Name:

Last Name:

Today's Date:

Date of Last Visit:

Address:

City:

State:

Zip Code:

Date Of Birth:

Social Security Number:

Marital Status:

Email:

Home Phone:

Work Phone:

Cell Phone:

Do you have Insurance? Yes No

Has anyone in your family been seen in our office? Yes No

If a family member has been seen in our office, please provide their name below:

INSURANCE INFORMATION

Policy Holder Information:

First Name:

Last Name:

Date Of Birth:

Employer:

Insurance Carrier:

ID#:

Cell Phone:

Group Number:

Subscriber ID Number:

Subscriber Social Number:

Insurance Phone Number:

Secondary Policy Holder Information:

First Name:

Last Name:

Date Of Birth:

Employer:

Insurance Carrier:

ID #:

Cell Phone:

Group Number:

Subscriber ID Number:

Subscriber Social Number:

Insurance Phone Number:

Physician Name:

Physician Phone:

MEDICAL HISTORY

Please Answer the Following:

Sex:

Height:

Weight:

Do you smoke or use tobacco?

Yes No

If Female, Please Answer the Following:

Are you taking Birth Control Pills? Yes No

Are you pregnant?

Yes No

If yes, # of weeks:

Are you nursing?

Yes No

Do you have, or have you ever had any of the following medical conditions? (Mark NONE if not applicable) :

Abnormal Bleeding
  Alcohol Abuse
  Allergies
  Anemia
  Angina Pectoris
  Arthritis
  Artificial Bones
Artificial Heart Valve
  Asthma
   Blood Transfusion
   Cancer - Chemotherapy
   Colitis
   Congenital Heart Defect
   Cosmetic Surgery
   Diabetes
   Difficulty Breathing
   Drug Abuse

  Emphysema
  Epilepsy
  Fainting Spells
  Fever Blisters
  Frequent Headaches
  Glaucoma
  Hay Fever
  Heart Attack
  Heart Surgery
  Hemophilia
  High Blood Pressure
  HIV+ AIDS
  Kidney Problems
  Liver Disease
  Low Blood Pressure
  Mitral Valve Prolapse
  PaceMaker

  Pneumocystis
  Psychiatric Problems
  Radiation Therapy
  Rheumatic Fever
  Seizures
  Shingles
  Sickle Cell Disease
  Sinus Problems
  Stroke
  Thyroid Problems
  Tuberculosis
  Ulcers
  Venereal Disease
  Yellow Jaundice
  NONE

Do you have, or have you ever had any of the following ALLERGIES? :

  Aspirin
  Codeine
  Dental Anesthetics
  Erythromycin
  Jewelry
  Latex
  Metals
  Penicillin
  Tetracycline
  NONE

OTHER:

Please list ALL medications currently being taken:

Medication name:

Dosage:

Reason for taking:

Medication name:

Dosage:

Reason for taking:

Medication name:

Dosage:

Reason for taking:

Is there any disease, condition, or problem that you think this office should know about that is not covered above? If yes, please describe below:
Yes No

Additional Medications:

Notes:

By checking this box, I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold Snow Family Dentistry, or any member of the staff, responsible for any errors or omissions that I have made in the completion of this form.

DALLIN R SNOW, D.M.D.

FINANCIAL POLICY & DENTAL BENEFITS CONSENT

Thank you for choosing Snow Family Dentistry as your Dental Provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require that you read, and sign prior to any treatment.

All Patients must legally complete all Forms prior to being seen by the Doctor.
All treatment estimates are good for 90 days.
Full payment is due at the time of service. We accept cash, check, Visa/ MasterCard, and Discover.
A $25.00 Charge is incurred for returned checks, and all future appointments must be paid in cash or credit card at the time of service.
Any balance left unpaid after 30 days will incur a monthly interest rate of 1.2%. Balances left 90 days or more will be turned over to a collection agency and the patient may be dismissed from the practice.

Regarding Insurance

We accept assignment of insurance benefits. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. Please be aware that the estimated co-pays that we give you are estimates. We do not guarantee any insurance coverage. It is your responsibility to find out what is and is not covered. You will be responsible for any balance not paid by your insurance company.

Adult Patients

Adult patients are responsible for full payment at time of service.

Minors

The adult accompanying a minor to his/her appointment is responsible for payment at the time of service. Minors will not be treated if unaccompanied or if arrangements have not been made prior to the time of service.

Missed Appointments

There will be a $50 fee for appointments missed or cancelled without 48 working hours’ notice in advance. This will help us cover a portion of our costs to make up for the time reserved especially for you. Please help us serve you better by keeping your scheduled appointments! Excessive missed or cancelled appointments will result in having to secure your appointment with a credit card to be billed for the amount of the appointment if missed or cancelled and/or dismissed from the practice. Thank you for understanding our Office Policy. Please feel free to let us know if you have any questions or concerns.

By checking this box, I have read and understand the above financial policy.

Signature (please hold down mouse button and sign):

HIPAA ACKNOWLEDGEMENT AND NOTICE OF PRIVACY PRACTICES

This Notice Describes How Health Information about You May Be Used and Disclosed and How You Can Get Access to This Information

Snow Family Dentistry is required by federal and state law to maintain the privacy of your health information. We are also required to give you this Notice of Privacy Practices that are described in the Notice while it is in effect. This Notice takes effect January 1^st, 2019 and will remain in effect until we replace it.

You have the right to review our privacy practices, the right to access any health information or amendments made to it. You also have the right to an accounting of disclosures and restrict uses of communicating health information.

We may use and disclose health information about you for treatment, payment, or health care operations (which does include communication with dental specialists or physicians).

We will not use your health information for any manner of direct or indirect personal gain or other unauthorized use.

We may use or disclose your health information when we are required to do so by law.

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes.

We will not use or disclose your health information for any reason other than those listed without your written authorization.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. For more information about our privacy practices, please contact our office manager at 480-982-7289.

I have read and understand Snow Family Dentistry privacy practices.

I consent for Snow Family Dentistry to disclose my protected health information as described.
Signature (please hold down mouse button and sign):

In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose (i.e., use of photos, if any are taken of patient). If you give us an authorization, you may revoke it in writing at any time.

I authorize the use of my health information for any other purpose other than what is stated in the Notice of Privacy Practices.

I do not authorize the use of my protected health information for any other purpose other than what is stated in the Notice of Privacy Practices.

Please Print Name

Signature (please hold down mouse button and sign):

PATIENT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

DALLIN R SNOW, D.M.D.

FINANCIAL POLICY & DENTAL BENEFITS CONSENT

HIPAA ACKNOWLEDGEMENT AND NOTICE OF PRIVACY PRACTICES