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Patient Registration Form

Pickett Family Dental

1135 Keller Pkwy,
Keller, TX 76248
(817) 431-5514

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )

Please present your insurance card to be photocopied for our records.

Secondary Insurance Details( * mandatory to fill )
Responsible Party( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )

I attest to the accuracy of the information on this page.

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Medical History( * mandatory to fill )

Please select any of the following which may apply to you now or in the past:

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  •  Heart Disease
  •  Stroke
  •  Diabetes
  •  Early-Term Birth
  •  Cancer
  •  Dementia
  •  Yes
  •  No
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  •  No

We offer a variety of services to enhance your comfort, and keep your smile beautiful. 

  •  Whitening/Bleaching
  •  Traditional Braces
  •  Headache/Migraine Therapy
  •  Night/Sports/Snoring Appliances
  •  Sedation
  •  Veneers
  •  Implants
  •  Invisalign (clear braces)
  •  Extended Payment Plans
  •  Replace Missing Teeth
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Dental History( * mandatory to fill )
  •  3 months
  •  4 months
  •  6 months
  •  not routinely
  •  0
  •  1-3
  •  4-6
  •  7-9
  •  10(or more)
  •  Yes
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Bite and Jaw Joint

  •  Yes
  •  No
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Smile Characteristics

  •  Yes
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Tooth Structure

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Gum and Bone

  •  Yes
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Consent to Proceed( * mandatory to fill )

I authorize Dr. Tyson Pickett and/or such associates or assistants as s/he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments. 

I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation. 

I understand that as part of the dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. Dental materials and medications may trigger allergic or sensitivity reactions. 

After lengthy appointments, jaw muscles may also be sore or tender. Holding one’s mouth open can, in a predisposed patient, precipitate a TMJ disorder. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required. 

I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal. 

I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past. I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva or Actonel, may result in complications of non-healing of the jaw bones following oral surgery or tooth extractions. 

I do voluntarily assume any and all reasonable medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of standard dental preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions. 

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Office Policies and Patient Responsibilities( * mandatory to fill )

Thank you for choosing Pickett Family Dental for your oral health needs. It is our goal to provide you with a positive experience. Over the past few years, the practice of dentistry has become more complicated for doctors and patients alike. 

Because of the growing complexity of the insurance business, we feel that we can no longer assume that patients fully understand the relationship between the insurance company, the doctor, and themselves. In an effort to clarify this relationship, we have established a set of guidelines regarding financial responsibility and office policies. 

We will file your insurance for you

* As a service to our patients with insurance, we will bill your carrier on your behalf to maximize your benefits. Patient portions are estimated based on information supplied by your insurance carrier to us and are not guaranteed to be exact, therefore, any amount not covered by your insurance is your responsibility.

* It is your responsibility to understand your insurance plan coverage. If you do not understand your policy, you may wish to contact them to review and verify your benefits. Not all services are a covered benefit in all contracts. Some insurances arbitrarily select certain services or treatment codes which they will not cover. Our office never guarantees that your insurance will pay for all services. We will make every attempt to file your claim as straightforward and simple as possible. However, if for any reason your claim is denied, you are responsible for the amount due on your account.

* If we do not receive payment from your insurance carrier within 90 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. 

Payment Options

You can choose from:

* Cash, Check, Visa, MasterCard, American Express or Discover Card.

* There is a $20 charge for returned checks.

* We offer a courtesy accounting adjustment to patients who pay one week prior to treatment for treatment plans of $300 or more. If advanced payments are made by credit card, we offer a 2% savings, if by cash or check; we offer a 5% savings.

* NO INTEREST1 Payment Plans2 from Care Credit

- Allow you to pay over time with NO INTEREST1

- Convenient, low monthly payment plans2 also available

- No annual fees or pre-payment penalties

* Pickett Family Dental requires payment at time of service 

Collection Efforts

* We will send you three statements regarding your balance. The second statement is considered past due. If you should receive a third statement noted “Final”, the account will be turned over to a collection agency. If are sent to a collections agency, a 35% collections fee will be added to your balance. 

Missed appointments, Late Cancellations, & Non-Compliance 

* Please keep in mind that appointments are time-slots reserved specifically for you. We require 48-hour advance notice if you are unable to keep your scheduled appointment. As a courtesy, we offer appointment reminder emails, text messages and calls which will allow you to cancel or reschedule at that time. However, it is ultimately your responsibility to keep track of your appointment whether you receive a reminder or not.

* If you miss an appointment without 48-hours advance notice or cancel/reschedule within the same time period, a fee of $75 per hour scheduled may be incurred on your account. This fee is not billable to your insurance.

* If you are more than 20 minutes late, your appointment may be cancelled, and you will need to reschedule. We encourage new patients to show up 15 minutes early to complete their registration.

* Patients with repeat cancellations or missed appointments may be discharged from our practice

* Abusive/inappropriate behavior towards staff or other patients may result in dismissal of your care from our practice.

  •  I have read the above conditions of treatment and payment and agree to their content
  •  I do not agree to the content above and/or do not want to disclose my SSN. I certify I have read the below statement, understand and agree to it.*

*I realize this is my choice and I can still get treatment here. I do understand this comes with the following changes: 1) all treatment will need to be paid in full at time of service, 2) insurance will reimburse me and not my dentist, 3) I must pay with credit, check or cash, 4) no payment arrangements will be possible, and 5) often insurance cannot be verified and estimates will be less accurate.

1If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required. 2Subject to credit approval

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Consent for Use and Disclosure of Health Information( * mandatory to fill )

PLEAE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment payment activities and healthcare operations. 

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare, operations of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice is available on our website. We encourage you to read it carefully and completely before signing this consent. 

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices; we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. 

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: 

Contact Person: Pickett Family Dental

Telephone: 704-375-8577 Fax: 704-331-9987

Address: 411 Billingsley Road, Suite 102 Charlotte, NC 28211 

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance of this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent. 

Signature: I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form I am giving my consent to your use and disclosure of my protected health information to carry out treatment payment activities and health care operations.

Please list any persons you wish to have access to your account: (All areas of account will be accessible, unless documented below.)

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