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Patient Intake Form

Buzz Nabers, DDS

2061 Thunderhead Rd, Knoxville, TN 37922, USA,
Knoxville, TN, 37922
(865) 531-0100

Patient Details( * mandatory to fill )
Dental Insurance Information( * mandatory to fill )
  •  Yes
  •  No
Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will recieve. Thank you for answering the following questions.

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  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
Do you have, or have you had, any of the following?
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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will recieve. Thank you for answering the following questions.

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OFFICE POLICIES & PATIENT AGREEMENTS( * mandatory to fill )

All patients, new and established, must complete our Patient Registration forms and sign that they haveread, understand, and agree to our office policies prior to being seen by any dental professionals. It is our goal for our patients to understand their treatment needs as well as their financial responsibility before any treatment begins.

UNCONFIRMED/MISSED APPOINTMENTS: We don’t charge our patients fees if you occasionally have to reschedule or miss an appointment, but we do ask that you confirm your appointment if you plan to keep that time reserved specifically for you. If you must change an appointment, we request the courtesy of being notified in advance so we can accommodate our other patients, or offer the time to another patient needing treatment. If you have not confirmed by the day of the appointment, your reserved time slot is subject to being shortened or replaced if another patient needs treatment. For multiple or subsequent late arrivals and cancellations, there may be a fee charged to your account at our discretion. We value your time and do our best to stay on schedule to see you at your appointed time, so we ask that you extend the same courtesy as we also have a very busy schedule to keep.

FINANCIAL POLICIES: Payment is due in full at the time of service. For our patients with dental insurance benefits, we require that you be responsible for any estimated copays/deductibles at the time services are rendered. For any treatment which requires more than one appointment, the estimated patient portion will be due, in order to reserve your initial appointment, unless prior arrangements have been made with our office. For your convenience, we accept cash, checks, Care Credit, and most major credit cards over the phone, online, and in office.

INSURANCE POLICIES: For our patients with insurance, we make our treatment recommendations based on what we believe is the very best treatment, regardless of your specific insurance coverage. Insurance coverage is designed to cover minimal to standard care, and for that reason it is not uncommon for dental benefits to not cover all of our fees.

As a courtesy to our patients, we will be happy to electronically submit all documents for your claim to be processed with your insurance company based on the information you provide us. However, it’s important to understand that you are responsible for your account with us, regardless of what your insurance company does or doesn’t pay. Your insurance plan is a contract between you and your insurance company. We are simply a third party providing a service to you.

We will submit all the necessary documents and information along with your claim, however, this DOES NOT GUARANTEE PAYMENT by the insurance company. The final determination of payment will be made by your insurance benefits provider at the time the claim is processed. Benefits payable are determined according to the insured’s eligibility, the limitations and exclusions (including pre-existing limitations), and conditions of the plan. Even after receiving a pre-estimate, your benefits provider will not guarantee their information, so we regret that we cannot be responsible for any discrepancies in benefits represented. If benefits have not been paid by your insurance company after 60 days of the completion date, the entire balance becomes your responsibility. If you have paid the balance off and we later receive a payment from your insurance company, your account will be credited and we will issue a refund check upon your request.

I have read and understand this document in its entirety; outlining the office and financial policies of Buzz Nabers, and agree to these terms.

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