If you are completing this form for another person:

Primary

Secondary

Do you have, or have you had, any of the following?

CARDIOLOGY

MUSCOSKELETAL

IMMUNOLOGICAL

ENDOCRINE

GENERAL

RESPIRATORY

NEUROLOGICAL

OTHER

Are you allergic, or have you reacted adversely, to any of the following?

Please list all Medications (including OTC), Vitamins, Supplements, Contraceptives, etc. that you are currently taking, or have taken, within the past 6 months. If you require additional room, notate that you are utilizing the back of this page.

Patients are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my Dentist, or any other member of his/her staff, may not be responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I also understand that I will have the opportunity to discuss all relevant health issues and/or my medical history prior to treatment.

Dr. S. K. Smith (Dental Office) is required by federal law to provide a Notice of Privacy Practices (Notice), which describes how medical information the Dental Practice maintains about patients may be used and disclosed and how patients can access this information.

This Notice is located in the binder titled Notice of Privacy Practices, which was handed to me by the front desk staff with this form. I acknowledge that the Notice is also available for review at www.drsksmith.com and that I may request a copy of the Notice from the front desk to take home with me. Please review the Notice carefully. The Dental Practice may amend the Notice from time to time. All amendments apply retroactively.

By signing below, I acknowledge that I received a copy of the Notice and have been given the opportunity to read and review the Notice.

Dr. Smith and teams' primary mission is to deliver the finest and most comprehensive periodontal services available today. We want your dental care experience to be as seamless as possible. To best assist you with the investment in your dental health, we have outlined our payment options.

Insurance

Our office will assist you in submitting dental insurance claims to dental insurance plans and companies. We currently participate with PPO's from Aetna, Cigna, MetLife, Guardian, and Delta Dental. We no longer participate in discount programs. If you believe the treatment or diagnosis should be billed to any other (medical) insurance, we will provide you with copies of the dental insurance forms that you can submit to the insurance of your choice. The insurance reimbursement if applicable is based on a contract between you and/or your employer and your insurance carrier.

Due to constantly changing insurance regulations, benefits and deductibles, we are only able to approximate your insurance balance. If your insurance pays more than expected, you will be credited with the difference. If your insurance company pays less than expected, you will be charged the difference these fees are expected to be paid in full within 60 days. If payment is not received within 60 days a 1.5% finance charge (18% annually) will be added to any balance.

Insured Payment Options:

20% of the services rendered to be paid at the time appointment is scheduled.

OR

If predetermination has been received by our office, your patient portion will be due in full.

Uninsured Payment Options: These options only apply if you do not have dental insurance.

Option 1: 50/50 split 50% down when scheduling and 50% at the time of service (cash, credit, debit, check). We accept MasterCard, Visa, Discover, and American Express.

*5% off for seniors only (cash, credit. debit, check)

Option 2: Outside financing, for those who would prefer an extended payment plan.

Care-Credit Is a credit card specific for any health care treatment. This plan may be used like any other credit card to pay for treatment and or services in our office.

To utilize this option, your total due must be over $1000.00 and can choose from 24, 36 or 48 months (@ 14.90% current APR until paid in full).

Cancellation Policy: Our office requires two business days or 48 hours' notice for any changes in scheduling. For appointments changed or canceled under 48 hours' or for no shows, a fee will be accessed in the amount of $100 per hour for any surgical or doctor appointments, or a $75 flat fee for period-maintenance appointments.

If you have questions regarding your dental insurance or payment policy or procedures, please do not hesitate to ask our staff. They are well informed and up-to-date.

This form is used to authorize the release of my protected health information as required by federal and state privacy laws. I understand that, by signing below, this authorization allows the Dental Practice to release my protected health information to a person or organization I choose. I understand that my treatment may not be conditioned upon my willingness to sign this authorization unless otherwise permitted by law. I also understand that my health information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient(s) and is no longer protected by the Privacy Rule (HIPAA).

I request and authorize

to release healthcare information of the patient named above to:

Extent of Authorization

**OR**

This Authorization will expire on

I understand that I may revoke this authorization at any time by submitting a request in writing to this Dental Practice, at 357 S. Gulph Road, Suite 250, King of Prussia, PA 19406, but such revocation is not effective until delivered to the Dental Practice and is not effective as to health records already disclosed under this authorization.