New Patient Packet Patient Details

  •  New Patient
  •  Update
  •  Child
  •  Student
  •  FULL-TIME
  •  PART-TIME

New Patient Packet Contact Information

How do you know about us?

New Patient Packet Emergency Contact Information

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient's address

New Patient Packet Employment Information

New Patient Packet Insurance Information

New Patient Packet Primary Insurance

New Patient Packet Secondary Insurance

New Patient Packet Medical History

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FEMALE PATIENTS

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  •  No

Do you have, or have you ever had any of the following? (select all that apply):

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New Patient Packet Medical History (continuation)

All patients: are you allergic to or have you ever had any reaction to the following? (check all that apply):

  •  Yes
  •  No
  •  Yes
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MEDICATION INFORMATION

All patients: are you currently taking any of the following? (select all that apply):

  •  Yes
  •  No
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New Patient Packet Dental History

Previous Dentist Information 

Dental History

  •  Excellent
  •  Good
  •  Fair
  •  Poor
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Child/minor patients: please answer the following questions

  •  Yes
  •  No
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PRIMARY PHYSICIAN INFORMATION

New Patient Packet Acknowledgement of Privacy Practices

My signature confirms that I have been informed of my rights to privacy regarding my protected personal and health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand the terms in which my personal health and identification information may be used.

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. 

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  •  I Give Permission for the Following Communications to Be Used by Dr. Nghi Tran, D.d.s. (Please Select All That Apply)
  •  Cell phone
  •  Text Message reminders permitted
  •  Home phone
  •  Work
  •  E-Mail
  •  I Am Granting Permission for Dr. Nghi Tran. D.d.s. To Disclose Their Identity to Anyone Who May Answer My Home, Work or Cell Phone.
  •  I Am Granting Permission for Dr. Nghi Tran, D.d.s. To Leave a Message With Any Person Who May Answer My Phone or on My Voicemail of the Following Numbers (Please Select All That Apply)
  •  Home Phone
  •  Cell Phone
  •  Work Phone
  •  None- please just ask for a call back
  •  Other

New Patient Packet PATIENT CONSENT-PAYMENT AUTHORIZATION - SIGNATURE ON FILE

To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status of if my medication changes, I shall inform the dentist and staff at the next appointment without fail. 

I hereby authorize payment directly to dr. Nghi tran, D.D.S. Of the dental benefits otherwise payable to me. 

I hereby authorize Dr. Nghi Tran, D.D.S. to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals. 

I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. 

By signing below, I acknowledge that I have read and understand the statements mentioned above.

 

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New Patient Packet Financial Guidelines

We are committed to providing you with the best care possible to achieve total oral health. In order to achieve these  Goals, we need your assistance and your understanding of our financial guidelines.

Insurance

We accept all major dental insurance payments, however we may not be an in network provider for your plan. If we are not an in network provider, review your plan details, as in many cases insurance reimbursement is very similar.

* No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference. 

* Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service. 

Payments 

* Patient portion or patient co-pay is due at the time services are rendered - unless prior financial arrangements have been made. 

* Payment Information:

* All major credit cards are accepted (Visa, MasterCard, Discover)

* Various financing options with CareCredit and Lending Club 

* Balances left over 90 days will incur an 10% or $10 minimum monthly finance charge. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. 

Short Cancelled/ Missed Appointments

* Please give 48 hours notice if you are unable to keep your reserved time. Unless an emergency occurs, we expect to run on time for your appointments, and we appreciate the same courtesy from you.

* After the first short canceled or missed appointment, a $35 or higher will be charged based on scheduled procedure. 

By signing below I acknowledge I have read and understand the guidelines above.  

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New Patient Packet General Dentistry Informed Consent

You have the right to accept or reject dental treatment recommendations by your dentist. This form is intended to provide you with an overview of potential risks and complications of the recommended procedure, alternative treatment or the option of no treatment. It is very important that you provide your dentist with an accurate medical history before, during, and after treatment. It is equally important that you follow your dentist advise and recommendations regarding medications, pre and post treatment instructions, referral to another dentist or specialist and return for schedule follow up appointments. If you fail to follow you may increase the chance of poor outcomes. Please read the items below and sign at the bottom of the form. Do not sign this form of until you have read, understood and accepted each item carefully. Be certain your dentist has addressed all of your concerns to your satisfaction before commencing treatment. Please initial the following:

WORK TO BE DONE: I understand that I am having the following treatment done:

 

  •  Exam, X-Ray, and Cleaning
  •  Cleaning
  •  Exam
  •  Crown
  •  Extraction
  •  Impacted teeth removal
  •  Root canal
  •  Dentures
  •  Local Anesthesia
  •  Filling
  •  Examination, Xrays and dental prophylaxis (cleaning):a routine dental prophylaxis involves the removal of plaque and calculus above the gum line and will not address gum infection below the gum line called periodontal disease. Some bleeding after a cleaning can occur, however, should it persist and if it's severe in nature, the office should be contacted. I understand that the initial visit may require radiographs in order to complete the examination, diagnosis and treatment plan.
  •  CHANGES IN TREATMENT PLAN: I understand the recommended treatment and my financial responsibility as explained to me. I understand that by signing this consent I am no way to obligated to any treatment. I also acknowledge that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered, during examination. Ex: root canal therapy following routine restorative procedure. I give my permission to my dentist to make any/all changes and additions as necessary. These changes will be discussed with me and I will have the opportunity to verbally agree or declined the changes. Unless it is not practical due to a dental/medical emergency.
  •  DRUGS MEDICATIONS LOCAL ANESTHESIA AND SEDATION: I understand that antibiotics, analgesics, and other medications can cause allergic reaction such as redness and swelling tissue, pain, itching, vomiting and/or anaphylactic shock. I have advised my dentist of all medications I am currently taking, including but not limited to prescription medications, over the counter medications, herbal remedies, and alternative medications. I further understand that failure to advise my dentist of any medication, I am taking prior to my dental procedure may have unforeseen negative consequences for me. Women of childbearing age need to know antibiotics may make birth control medication ineffective and need to use other methods of birth control. Some adverse can occur from local anesthesia such as loss of feeling in teeth, lip tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time and/or permanent nerve damage.
  •  FILLINGS: I understand that care must be exercised in chewing on filling teeth, especially during the first 24 hours to avoid breakage. I understand that a more extensive restorative procedure that originally diagnosed may be required due to additional or extensive decays, I understand that significant sensitivity is a common after effect or newly placed filling. With larger cavities, root canals and/or crowns may be necessary to stabilize my tooth/teeth. I understand it is sometimes not possible to match the color of natural teeth exactly with artificial filling material.
  •  ENDODONTIC THERAPY:I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur for the treatment, and that occasionally root canal filling material may extended through the tooth which does not necessarily affects the success of the treatment. I understand that endodontic files and reamers are very fine instruments and stresses and defects in their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy) or the root canal may be short or have other complications and may need to be redone. My root might also be perforated during the procedure causing me to lose the tooth. I understand that tooth may be sensitive during treatment and even remain tender for sometime after treatment. Hard to detect root fractures is one if the main reasons why root canals fail. Since teeth with root canals are more brittle that other teeth, a crown is necessary to strengthen and preserve the tooth. It also prevents a root canal from being re-infected.
  •  REMOVAL OF TEETH: Alternatives to removal of teeth have been explained to me (root canal, crown and bridge procedure, periodontal therapy etc) I understand removing teeth does not always remove the infection, if present and may be necessary to have further treatment. I understand the risk involves in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, lost feeling in my teeth, lip tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time, or fracture jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility. Removal of the tooth leaves a socket that may not heal properly to allow the placement of an implant or proper restoration. A graft allows the socket to heal with the intention of preserving the bone of optimum results. Trismus, limited jaw opening due to inflammation or swelling, can occur as well as bleeding. Numbness can occur in teeth, lip, tongue and chin, due to closeness of tooth roots to the nerves which can be bruised or injured, and most often sensation returns but the loss may be permanent.
  •  CROWNS, BRIDGES, VENEERS: I understand that sometime it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which come off easily and that I must be careful to ensure that they are kept on until the permanent crown is delivered. I realized the final opportunity to make changes (shape, fit, size, color) will be before cementation. It is also my responsibility to return for permanent cementation within 20 days for tooth preparation. Excessive delays may allow for tooth movement or additional decay which may be necessary a remark of the crown, bridge, or cap and an additional cost for the patient may occurred. I understand there will be additional charges for remarks due to my delaying on permanent cementation. If temporary crown falls off, it's my responsibility to return to the office within 3 days or there may be an additional fee.
  •  PERIODONTAL DISEASE: I understand that I have been diagnosed with a serious condition, causing gums and bone inflammation and/or loss and that the results could lead to the loss of teeth. Alternative treatments have been explained to me, including gum surgery, tooth extractions and/or replacement. I understand that any dental procedure mat have a future adverse effect on my periodontal condition.
  •  PARTIALS AND DENTURE: I understand the wearing of partial/dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placement of denture immediate after extractions) may be painful. Immediate dentures may require considerable adjusting and several relines, A permanent reline will be needed at a later date. This is not included in the denture fee. I understand that this is my responsibility to return for delivery of my partial/denture. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than 30 days, additional charges could be incurred.
  •  TEMPORARY MANDIBULAR JOINT DYSFUNCTION (TMJ): I understand that symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower neat the end subsequent to routine dental freatment wherein the mouth is held in the open position. However; symptoms of TMJ associated with dental freatment are usually transitory in nature and well tolerated by most patients. I understand that should the need for treatment arise, then I will be referred out to a specialist or even hospitalization if complications arise during or after freatment, the cost of which is my responsibility. 

I understand that dentistry is not an exact science and that therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental freatment which I have requested and authorized.

I hereby authorize any of the doctors or dental auxiliaries to proceed with and perform the dental restorations and treatments as explained to me, I understand that this is only an estimate and subject to modifications depending on unforeseen or undiagnosable circumstances that may arise during the souses of treatment. I understand that regardless of any dental insurance I may have, be responsible for payment of the dental fees. I agree to pay any attorneys fees, or court cost that may be incurred to satisfy this obligation. I UNDERSTAND THAT ALL PAYMENTS/ FEES ARE FINAL WITH NO REFUNDS.

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