PATIENT INFORMATION
Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
Date:
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EMERGENCY CONTACT

This should be the nearest relative who does not live with the patient.

INSURANCE INFORMATION
Primary Insurance
Date of Birth: 
Secondary Insurance
Date of Birth: 
Insurance Authorization

All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissionsand I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. Iauthorize Bethany B. Brenner, DMD, LLC to act as my agent in helping me to obtain payment from my insurance companies. I authorize paymentto Bethany B. Brenner, DMD, LLC. I permit a copy of this authorization to be used in place of the original. I give Bethany B. Brenner, DMD, LLC, its employees, and/orother agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or textmessage) and email addresses, for the purpose of treatment, insurance, or payment.

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PAYMENT POLICIES
Thank you for taking the time to understand our payment policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our office staff for clarification.
For Patients with Dental Insurance

We accept dental insurance assignments, with the understanding that any uninsured portion not covered by your insurance plan is to be paid by you at the time of service. As a courtesy, our office will file all applicable insurance forms. Please note that although we strive to provide accurate information, such information is not a guarantee of payment or eligibility with your insurance company and is only an estimate. Your dental insurance plan is a contract between you, your employer, and the insurance company. Depending on your specific insurance plan, your dental insurance may not fully cover our office dental fees for the services we render. The difference between our office dental fees and your insurance reimbursement is your responsibility.

Returned Checks
Personal checks that are returned due to "insufficient funds" are subject to a $30.00 service fee.
Service Charge

Payment is due at each appointment. I agree to pay any outstanding insurance balance within 60 days. If I do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1.5% per month (or a minimum charge of $2.50 for a minimum balance of $25.00) which is an annual percentage rate of 18% applied to the last month’s balance. In case of default of payment, I promise to pay any legal interest on the balance due. Together with any collection costs and reasonable attorney fees incurred to effect collection of this account balance or any future accounts. Please be advised that there is a $50.00 fee charge for missed or broken appointments without 24 hours’ notice. To avoid this charge, kindly give us a minimum of 24 hours’ notice for any appointment cancellation. Feel free to contact us at any time with questions you may have.

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X-Ray/Records Release
There is a fee of $25.00 for any release of X-rays and/or records.
Minors

Adult patients are responsible for full payment at time of service. The adult accompanying a minor is responsible for payment. This office will not bill a non-custodial parent for services delivered to a minor. For unaccompanied minors, treatment may be denied unless charges have been pre-approved to a credit card or other payment arrangements have been made.

Authorization

I hereby authorize payment directly to Bethaney B. Brenner, DMD, LLC of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of the above-named patient's dental treatment. The information on the page and the dental/medical histories are correct to the best of my knowledge. I grant the right to Bethaney B. Brenner, DMD, LLC to release the patient's dental and/or medical histories and other information about the patient's dental treatment to third-party payers and/or other health professionals.

Date: 
DENTAL HISTORY
Dental Hygiene
Are you interested in regular hygiene cleanings?
Yes No
Other Concerns
Smoking/Dipping
Biting Cheeks or Lip
Popping/Clicking
TMJ
Tooth Colored Fillings
Wisdom Teeth
Nail Biting
Sleep Apnea
Limited Orthodontics
Orthodontic Treatment
Burning Tongue
Tooth Replacement
Fractured Tooth Syndrome
CPAP
Implants
Jaw locks open/closed
Stain
Chew on One Side
Snoring
Teeth Straightening
Retainer
Dry Mouth
Wisdom Teeth Extraction
Cosmetics
Smile Makeover
Dental Phobias
Allergic to Nuts
Allergic to Spices
MEDICAL HISTORY
How is your general health? Good Fair Poor
Last visit:
Do we have permission to contact your doctor regarding your care? YesNo
Have You Ever Had:
Check all that apply.
Arthritis
Arteriosclerosis
Birth Defects
Cancer/Chemotherapy
Emotional Problems
Head Injury
Heart Murmur/Trouble
History of Substance Abuse/Drug Addiction
Kidney Problems
Numbness of arms or hands
Swollen/Painful joints
Allergies
Asthma
Blood Disease
Diabetes
Endocrine Problems
Intestinal Disorders
Hepatitis A, B, or C
Hypertension (High blood pressure)
Liver Problems
Pneumonia
Anemia
Bruise Easily
Dizziness
Epilepsy
Seizures
Fainting
Hearing Disorders
High/Low Blood Sugar
Hypotension (Low blood pressure)
Nervous Disorder
Rheumatic Fever
Heart Attack/Stroke
Heart Surgery
Pacemaker
Artificial Valves
Congenital Heart Defect
Mitral Valve Prolapse
Artificial Bones/Joints
Shingles
HIV/AIDS
Blood Transfusion
Fever Blisters
Sinus Problems
Severe/Frequent Headaches
Radiation Treatments
Psychiatric Problems
Tuberculosis
Venereal Disease
Hemophilia
Abnormal Bleeding
Ulcers
Difficulty Breathing
Hospitalized for any reason
Emphysema
Glaucoma
Thyroid Disease
Angina
Gout
Chest Pain
Circulatory Problems
Congenital Heart Lesion
Cortisone Medicine
Convulsions
Herpes
Leukemia
Excessive Thirst
Hay fever
Heart disease
Hives/skin rash
Hypoglycemia
Irregular heartbeat
Lung disease
Osteoporosis
Parathyroid disease
Recent weight loss
Rheumatism
Sexually transmitted disease
Sickle cell anemia
Tattoos/body piercing
TMD/TMJ (jaw pain)
X-ray or cobalt treatment
Yellow jaundice
Chronic fatigue syndrome
Cough-persistent or bloody
Latex sensitivity
Smoker
Swelling of feet/ankles
Swollen neck glands
Tonsillitis
Tumor or growth on head/neck
Anaphylaxis
Alzheimer's disease
Renal dialysis
Have You Ever Had an Adverse Reaction Or Allergies To Any Medication Or Substance?
Check all that apply.
Acrylic
Asprin
Barbiturates
Codeine
Erythromycin
Latex
Metals
Nitrous Oxide
Novocaine
Penicillin
Sedatives
Sulfa Drugs
Tetracycline
Valium
Motrin
Ibaprofen
Statins
Clindamycin
Are you currently taking or have you ever taken any bisphosphonate drugs? These include: alendronate (Fosamax), clodronate (Ostac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), tiludronate (Skelid), zoledronic acid (Zometa). YesNo
Do you take or have you taken Phen-Fen or Redux? YesNo
Do you smoke or chew tobacco? YesNo
Do you use alcohol, cocaine, or other drugs? YesNo
Do you wear contact lenses? YesNo
Are you on a special diet? YesNo
Have you lost or gained more than 10 pounds in the past year? YesNo
Do you use more than two pillows to sleep? YesNo
Have you ever had any excessive bleeding requiring special treatment? YesNo
Have you been treated in a hospital in the last five years? YesNo
Do you wish to talk to the dentist privately about any problems/concerns? YesNo

All of the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.

Date: 
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