<p> Healthy Smile Dentistry 2645 Bethel Road Columbus, Ohio 43220 (614) 457-3300 </p><p>Patient ID # Patient Insurance Information Page 1 of 3</p><p>PERSONAL INFORMATION Date: ______Name: ______SS #: ______Address: ______City: ______State: ______Zip: ______Telephone: (Home) ______(Work):______(Cell) ______E-mail: ______Birth date: ______Sex: ______Marital Status: ______Spouse Name: ______Occupation: ______Referred by: ______</p><p>PERSON RESPONSIBLE FOR ACCOUNT</p><p>Name: ______Relationship: ______SS #: ______Address: ______City: ______State: ______Zip: ______Telephone: (Home) ______(Work) ______</p><p>DENTAL INSURANCE INFORMATION</p><p>Primary Insurance Co: ______Phone: ______Insurance Co. Address: ______Subscriber: ______Birth Date: ______Relationship: ______Member ID #: ______Employer: ______Group #: ______Secondary Insurance Co: ______Phone: ______Insurance Co. Address: ______Subscriber: ______Birth Date:______Relationship: ______Member ID #: ______Employer: ______Group #: ______</p><p>I understand that payment is my obligation regardless of insurance or any other third-party involvement.</p><p>SIGNATURE: ______DATE: ______Patient ID # Patient Medical Information Page 2 of 3 HEALTH INFORMATION Personal Physician Name: ______Personal Physician Address: ______</p><p>Allergies ❑ ✡▲❐❉❒❉■ ❑ ✤❅■▼❁● ✡■❅▲▼❈❅▼❉❃▲ ❑ ✬❁▼❅ ❘ ❑ ✰❅■❉❃❉●●❉■ ❑ ✴❅▼❒❁❃❙❃●❉■❅</p><p>❑ ✣❏❄❅❉■❅ ❑ ✥❒❙▼❈❒❏❍❙❃❉■ ❑ ✭❅▼❁●▲ ❑ ✳◆●❆❁ ❑ ✯▼❈❅❒ ✿✿✿✿✿✿✿✿✿✿✿✿✿✿✿✿✿✿</p><p>YES NO ❑ ❑ 1. Have you been hospitalized within the past 2 years? For what? ______❑ ❑ 2. Are you currently being treated by a physician? For what? ______❑ ❑ 3. Are you currently taking any medicines or drugs? What? ______❑ ❑ 4. Have you ever received counseling for excessive use of prescription drugs?______❑ ❑ 5. Have you ever had a skin rash or other reaction to metal jewelry? To What? ______❑ ❑ 6. Have you ever been involved with dental/medical legal activity? ❑ ❑ 7. Do you smoke or use other tobacco products? How much/often? ______❑ ❑ 8. Are you being treated for osteoporosis? ❑ ❑ 9. Are you pregnant? Are you Nursing? ______</p><p>CIRCLE ANY OF THE FOLLOWING MEDICAL CONDITIONS THAT YOU HAVE HAD</p><p>Abnormal Bleeding Chemotherapy Fever Blisters Hepatitis C/B/A Radiation Therapy</p><p>Alcohol Abuse Colitis Frequent Headaches High Blood Pressure Seizures</p><p>Allergies Congenital Heart Defect Joint Replacement/implants Kidney Problems Sexually Transmitted Disease </p><p>Anemia Diabetes Glaucoma Liver Disease Shingles</p><p>Angina Pectoris Difficulty Breathing HIV/AIDS Low Blood Pressure Sickle Cell Disease </p><p>Arthritis Drug Abuse Heart Attack Mitral Valve Prolapse Sinus Problems </p><p>Artificial Heart Valve Emphysema Heart Murmur Pace Maker Stroke</p><p>Asthma Epilepsy Heart Surgery Psychiatric Problems Thyroid Problems</p><p>Blood Transfusion Eating Disorder Hemophilia Rheumatic Fever Tuberculosis </p><p>Cancer Fainting Spells Heart Problems:______Ulcer</p><p>Facial Surgery Other Diseases (______)</p><p>Continued on Next page Patient Dental Information Patient ID # Page 3 of 3</p><p>Name of Previous Dentist: ______Date of Last Exam: ______</p><p>Previous Dentist’s Location:______Date Of Last Cleaning: ______</p><p>YES NO ❑ ❑ 1. Do your gums bleed while brushing or flossing? ❑ ❑ 2. Are your teeth sensitive to hot or cold liquids/foods? ❑ ❑ 3. Are your teeth sensitive to sweet or sour liquids/foods? ❑ ❑ 4. Do you feel pain in any of your teeth? ❑ ❑ 5. Do you have sores or lumps in you mouth? ❑ ❑ 6. Have you had any head, neck or jaw injuries? 7. Have you ever experienced any of the following problems in your jaw? ❑ ❑ ❁✎ clicking ❑ ❑ ❂✎ Pain (joint, earear, side side of of face)? face)? ❑ ❑ ❃✎ Difficulty in opening or closing youyour jaw? jaw? ❑ ❑ ❄✎ Difficulty in chewing? ❑ ❑ 8. Do you have frequent headaches? ❑ ❑ 9. Do you clench or grind your teeth? ❑ ❑ 10. Do you bite your lips or cheeks frequently? ❑ ❑ 11. Have you ever had any difficult teeth extractions in the past? ❑ ❑ 12. Have you ever had prolonged bleeding following tooth extraction? ❑ ❑ 13. Have you had any orthodontic treatment? ❑ ❑ 14. Do you wear dentures or partials? If yes, Date of placement: ______. ❑ ❑ 15. Have you ever received oral hygiene instruction regarding the care of your teeth and gums? ❑ ❑ 16. Do you like your smile?</p><p>Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize Healthy Smile Dentistry, LLC and the Dentist: Dr. Sahar Hamzeh, to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child, during the period of such dental care, to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment for all services rendered on my behalf or my dependents. Patient Signature______Date: ______</p><p>Doctor’s Signature: ______Date: ______Financial Policy</p><p>Dear Valued Patient,</p><p>Thank you for choosing Healthy Smile Dentistry for your dental care. We want to make your visit as easy as possible by providing information that will help you with our billing and payment procedures.</p><p>Payments:</p><p> At the time of your visit, you are responsible to pay any deductible, copayment, coinsurance, or outstanding balance as specified by your insurance company.</p><p> Any dental services not covered by your insurance company must be paid in full at the time of the appointment, unless you have made arrangements with us prior to your appointment.</p><p> If you do not have insurance, you will be expected to pay in full at the time of your appointment.</p><p> Payment can be made with cash, check, or credit card. Visa, MasterCard and Discover are accepted by our office. There is a $30.00 fee for any check returned by the bank for any reason. </p><p> Our office does offer a financing option through Care Credit. Our staff is available to answer questions and assist in the application process for this financing.</p><p> In the event of a divorce, both parents will be considered equally responsible for payment. If will be up to the parents to resolve divorce decree differences. </p><p>Insurance Benefits and Forms:</p><p> Healthy Smile Dentistry contracts with many insurance companies. If you have insurance with one of these companies, our staff will submit a claim for payment of services for you unless you instruct us not to. All needed insurance information must be provided by you before your appointment.</p><p> If Healthy Smile Dentistry does not contract with your insurance company, you will be responsible for any balance not paid by your insurance.</p><p> For the convenience of our patients, our staff will compose an estimated treatment plan for services. This is done with the information we have on file at the time of your appointment. Although we strive for accuracy, it is impossible to know every patient’s entire insurance policy. Therefore, our treatment plans are an estimate and we cannot guarantee payment for an insurance company. </p><p> If you have questions about your insurance coverage, you need to call your insurance company. Their telephone number should be printed on your insurance card.</p><p> Our staff is happy to help with insurance questions relating to how a claim was filed. We will also provide any additional information your insurance company might need to process the claim.</p><p>Financial Policy Acknowledgement: I have read or someone has read the form to me, and I received a copy of the above Financial Policy. I agree to follow the policy.</p><p>______</p><p>Printed Patient or Responsible Party Name Date</p><p>______</p><p>Signature for Patient or Responsible Party</p><p>Cancellation Policy</p><p>If you need to reschedule or cancel an appointment, please contact our office at least 48 hours in advance. If you cancel without a 48 hour notice or do not show up for your appointment, a fee of $50.00 will be applied to your account for each half hour of time you were scheduled. We realize that emergencies do arise, however to be courteous to our other patients we must insist that you arrive during your scheduled appointment time. In addition, a rescheduled appointment cannot be guaranteed. Repeated failure to keep your appointment may result in your being dismissed as a patient.</p><p>Patient Signature: ______Date: ______</p><p>Acknowledgement of Receipt of Privacy Practices Notice:</p><p>I, ______, acknowledge that I have viewed/received a copy Print Name of the Notice of Privacy Practices for Health Smile Dentistry, Ltd.</p><p>______Signature Date </p>