Patient Forms

Personal Information

Personal Information


Name:
Patient SSN:
Address:
Place of Employment
Occupation
Home Phone:
-
Work Phone:
-
Date of Birth:
 / 
 / 
E-mail address:
Name of Family Member Already a Patient Here:
Referred By:

Responsible Party

Who is financially responsible for treatment:

If other, please provide:

Provider Name:
Provider Address:
Provider Home Phone:
-
Provider Work Phone:
-
Name of Employer:
I will be paying today by:

Dental Insurance Information


Primary Insurance Co. Name:
Name of Subscriber / Holder:
Ins. Co. Phone:
-
SSN:
Subscriber Place of Employment:
Member Number:
Subscriber Date of Birth:
 / 
 / 
Secondary Insurance Co. Name:
Name of Secondary Subscriber / Holder:
Secondary Ins. Co. Phone:
-
Secondary Ins. Member Number:

Medical History:

Check all the conditions that apply to you:


Conditions
Are you allergic to:
Other Allergies:
Are you being treated by a Physician?
If yes, please explain:
My Primary Medical Physician is:
Primary Care Physician Phone:
-
Current Medications:

Dental History

Are You Experiencing:
Location:
In case of Emergency contact:
Emergency Contact Phone Number:
-

Authority to Treat

I give Houston Oral Healthcare Specialists authority to administer dental x-rays, local injections, anesthetics and, if requested, nitrous oxide or a tranquilizer in the subsequent treatment of my case. If I have a medical condition such as a heart murmur that requires premedication, I acknowledge that it is my responsibility to inform and remind the doctor, assistant or hygienist at the beginning of each visit.

PLEASE BE AWARE THAT YOU ARE RESPONSIBLE FOR ANY BALANCE THAT IS NOT PAID BY YOUR INSURANCE COMPANY

The above information is true and complete to the best of my knowledge. I agree to pay my copayment at the time services are rendered. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Electronic Signature: *

Please type your first and last name


I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*

I, Dr. Cummings, and my team are very sensitive to the cost of oral health care and the expense involved in providing the highest level of dental care possible to our patients. As it is our sincere desire to gain you as on of our periodontal family, we realize that if finances prevent you from obtaining the necessary treatment to regain your oral health, we all lose. Examination and consultations, maintenance and recall and emergency fees are payable the day the professional services are rendered. If non-surgical or surgical treatment is necessary, payment arrangements must be concluded before the appointment can be scheduled. In order to assist you in regaining your oral health, we offer you the following financial options:

I. CASH/CHECK

If you elect to pay for your entire treatment in one full payment, we offer a 5% discount.

II. Credit Cards

We accept VISA, Master Card, Discover and American Express.

III. In-House Financing

Please talk with your treatment coordinator for details on monthly credit or ACH debitplans.

IV. Third Party Financing

We offer third party financing through Care Credit.

V. Insurance

Please remember that the patient, not the insurance company, is ultimately responsible for payment of professional services. As a courtesy to you, we will accept assignment of insurance benefits for treatment. We ask that you make arrangements to pay the estimated amount the insurance will not pay at the time of service. No insurance is designed to pay 100% of dental treatment. Your specific dental plan benefit is a direct reflection of the quality of the plan selected by your employer. We have no control over these individual benefits. Your treatment plan is designed to restore you optimal oral health in the most practical, predictable and cost effective manner possible. If you treatment costs are more than your yearly plan benefit maximum, we offer multiple financial arrangements to help you obtain your needed treatment. Please understand though, that it is ultimately your responsibility to pay all fees incurred. If insurance payments is delayed over 60 days, you will be asked to make financial arrangements to begin payment on your account.

Note-Referring Dentist Fees

Please remember that your treatment plan does not include the treatment or cost of your referring dentist. For example: crowns on implants, dentures or bridges. Your referring dentist will have a separate fee for their services.

Again, Thank you for your trust and expression of confidence. Please feel free to discuss any questions with us openly and promptly.

I certify that I have read and understand the above financial policy.



Electronic Signature: (1)*

Please type your first and last name


I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.(1)*
I (first & last name):

hereby acknowledge that I have received a copy of this practice's Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this notice.


Electronic Signature: (1)(1)*

Please type your first and last name


I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.(1)(1)*