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Existing Patient Update Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

If you are completing this form for another person, what is your relationship to that person?

Medical Information

Are you currently under the care of a physician?
Are you in good health?
Has there been any change in your general health within the past year?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
Do you take any blood thinners?
Do you take aspirin on a regular basis?

Women Only Are you:

Pregnant?
Taking birth control pills or hormonal replacements?
Nursing?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following:

Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever / seasonal
Animals
Food / Other

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systematic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer / Chemotherapy / Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or type II
Eating disorder
Malnutrition
Gastrointestinal disease
GE Reflux / persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice, or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
Recurrent infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches / migraines
Severe / rapid weight loss
STDs / STIs
Excessive urination
ADD
ADHD
Sensory Processing Disorder
Oral Sensory Sensitivity
Has a physician or previous doctor recommended that you take antibiotics prior to your treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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HIPAA Privacy Authorization Form

Authorization for use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act)

I,

hereby authorize and request Melinda Marino,DDS to release my health information to:

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. Unless otherwise revoked, this authorization shall be in force and effect indefinitely until changes are made by the patient.

Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Consent for Services and Financial Policy

Thank you for choosing us as your Dental Care Provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. All patients must read and sign this form prior to seeing the doctor.

DENTAL INSURANCE: Our office will gladly work with you to help get the maximum benefit available to you. Most dental insurance plans do not cover 100% of your treatment cost. Therefore, you will be expected to pay your deductible and your estimated co-payment on the day that the services are rendered. We will gladly file your insurance claim as a courtesy. Many variables exist from carrier to carrier (i.e., restrictions): therefore, we cannot guarantee any estimated charges. Your policy and benefits are an agreement between you and the insurance company so ultimately you are responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits from your insurance company. If for some reason your insurance company has not paid their estimated portion within 60 days from the start of treatment, you are responsible for payment in full at that time. Treatment could be altered if your dental needs change. The patient will be notified of any change(s) in treatment. We will gladly file all dental claims for any given treatment, but we are not party to any insurance programs or contracts. The balance is YOUR RESPONSIBILITY whether your insurance company pays for your treatment or not. It is your responsibility to inform us of any changes in your insurance coverage.

REGARDING INSURANCE PLANS WHERE WE ARE A PARTICIPATING PROVIDER: All ESTIMATED portions and deductibles are due prior to treatment. In the event your insurance coverage changes to a plan where are a non-participating provider, please refer to the above paragraph. You are responsible for advising this office if you have a change in your insurance coverage PRIOR to your scheduled appointment.

TREATMENT PLAN ESTIMATES: We prepare TREATMENT PLAN ESTIMATES so that patients can understand their estimated cost of recommended restorative treatment prior to start. The Estimate is a good-faith attempt to predict the cost of your treatment based on the known facts when the estimate is made. As your treatment progresses, your dentist may determine in consultation with you that additional or a change in treatment may be necessary and that would change the estimated cost.

MISSED / BROKEN APPOINTMENTS: We respectfully ask that you give us a minimum 48-hour notice to cancel or reschedule your reserved appointment. We kindly ask you to reschedule hygiene visits within 30 days of your recommended recall schedule. A broken appointment is defined as one for which the patient failed to show-up or to cancel an appointment with less than 24 hours’ notice. As of January 1, 2022, this office will charge for broken appointments at a rate of $75 per hour. All charges for broken appointments must be paid before any other appointments will be scheduled. All adult patients are required to sign for minors/dependents and themselves.

ASSIGNMENT OF INSURANCE BENEFITS: I understand that services rendered to me by Dr. Melinda Marino, DDS, Associate Dentist, and/or Hygienist (collectively labeled as “Provider”) are my financial responsibility and that the Provider will bill my insurance company as a courtesy. I authorize my insurance company to pay my benefits directly to Provider. I understand that I will be fully responsible for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEIFTS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of professional service charges over and above this insurance payment.

I have been given the opportunity to pay my estimated deductible and co-insurance at the time of service. I have chosen to assign the benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the prompt payment of the claim by 25 days (electronically filed) or 45 days (paper mailed).

I authorize the Provider to release any information necessary to adjudicate the claim and understand that there might be associated costs for providing information beyond what is necessary for the adjudication of a clean claim. I also authorize the Provider to initiate a complaint to the insurance commissioner for any reason on my behalf.

I understand that should my insurance company send payments directly to me; I will forward the payment on to the Provider within 48 hours. I agree that if I fail to send the payment to the Provider, and they are forced to proceed with the collections process, I will be responsible for any cost incurred by the office to retrieve their monies. In the event the patient receives any check, draft, or other payment subject to this agreement, I will immediately deliver said check, draft, or other payment to Provider. Any violations of this agreement will, at Provider’s election, terminate Patient charge privileges with Provider, as well as bring any balance owed by Patient to Provider immediately due and payable.

I authorize the dentist 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 healthcare practitioners.

I grant my permission to your or your assignee, to telephone me at home, my work, or my cell phone to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to the contents.

Signature


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue