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Marea White DDS

2117 Central Dr Ste 100,
Bedford, TX 76021
8172830047

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
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Emergency Contact:

Responsible Party's Information( * mandatory to fill )
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Insurance information( * mandatory to fill )
Please complete the following for any Additional Insurance( * mandatory to fill )
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 receive. 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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To the best of my knowledge, the questions on this form have been accurately answered. 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.

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DENTAL HISTORY( * mandatory to fill )
  •  Sensitivity (hot, cold, sweet) Where? UR LR UL LL
  •  Jaw joint pain
  •  Teeth of fillings breakingTeeth of fillings breaking
  •  Grinding or clenching teeth
  •  Bleeding
  •  swollen or irritated gums
  •  Loose or shifted teeth
  •  Bad breathe
  •  Dentures
  •  Partial dentures
  •  Braces
  •  Periodontal (gum) treatmentsPeriodontal (gum) treatments

Please share the following dates:

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If I could change my smile, I would: Make them whiter; Straighter; Close spaces; Replace black fillings with tooth-colored restorations; Repair chipped teeth; Replace missing teeth; Replace old crowns that don't match,have a smile makeover.

On a scale 1-10, with 10 being the highest rating

Financial Policy( * mandatory to fill )

Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment.

Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, and Discover. Outside financing is available upon request and approval.

  •  Please check if you would like more information about financing options.

Please Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/ or legal charges incurred. 

Do You Have Insurance? 

* As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you, however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible.

* All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract.

* Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. 

* We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office.

* We ask that you pay the deductible and co-payment, which is the estimated amount not covered by your insurance company, by cash, check, MasterCard, Visa or Discover at the time we provide the service to you.

* Insurance payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.

* We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim. 

We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy. 

I HAVE READ,UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO MY DENTAL OFFICE.

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AUTHORIZATION FOR SIGNTURE ON FILE Release of information/Financial Responsibility( * mandatory to fill )

I hereby authorize the office of Marea White DDS, to affix any and all health insurance benefits due me.

I have reviewed all treatment plans and fees and agree to be responsible for all charges for dental services and materials not paid by my dental benefits plan. To the extent permitted under applicable law, I authorize the release of any information needed for my treatment.

This "Signature on File" will be valid unless otherwise rescinded by me, by signed documents. A photocopy of this document may act as an original.

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Acknowledgement of Receipt of Notice of Privacy Practices( * mandatory to fill )

* You May Refuse to Sign This Document

I have received a copy of this office's Notice of Privacy Practices. 

 

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