As required by law our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you, this office does not use this information to discriminate.

Do you have any of the following diseases or problems : (Check DK if you know Don't know the answer to the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please mark(x) your responses to the following questions.

Medical Information

Please mark (x) your response to indicate if you have not had any of the following diseases or problems.

Joint Replacement 

Allergies -Are you allergic to or have you had a reaction to 

To all yes responses, specify type of reaction.

Please mark (x) your response to indicate if you have not had any of the following diseases or problems.

Except for the conditions listed above, antibiotic prophylaxis no longer recommended for any other form of CHD. 

NOTE: Both Doctor and patient 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 questions , if any, about inquiries set forth above, have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they or do not take because of errors or omissions I may have made in the completion of this form.

PAYMENT IS REQUIRED FOR ALL DENTAL SERVICES AT THE TIME TREATMENT IS RENDERED. We accept Visa, MasterCard, Discover, American Express, Care Credit, Cash or Check.

INSURANCE FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY. We do, however, file dental insurance claims as a courtesy to our patients. We can ONLY make ESTIMATES regarding your insurance benefits based on the information provided by you and your insurance company. In the event your insurance company does not pay as much as expected, the remaining balance is due and payable immediately by you, the patient. Also, if we have not received payment from your insurance company within 60 days, YOU are responsible for paying the entire amount, and then to seek reimbursement from your insurance company. In the event that your account is ever over-paid, you will be given a credit on your account to be used for future dental care, or a refund will be issued.

In addition, your insurance may exclude or consider some services excludable. In the event this happens, you, the patient will be responsible for the total cost of the treatment. Not all insurance policies are identical, some have clauses which prevent your plan from covering standard dental procedures. STONEGATE DENTAL CARE PC cannot be held responsible for any clauses in your insurance policy. We strive to provide complete ESTIMATES to you, however, we may not have been informed by your insurance company of any specifics of the plan. If you are in doubt of what your plan covers, please request a pre-authorization of services.

ASSIGNMENT OF INSURANCE BENEFITS- I/We hereby assign directly to STONEGATE DENTAL CARE PC, dental benefits otherwise payable to me/us. I/We hereby authorize the release of any information relating to any claims. I/We understand that I/We are financially responsible for charges not paid by this assignment.

RETURNED CHECKS OR NSF ACH DEBITS- In the event your check is returned unpaid due to insufficient funds, you authorize your check to be electronically redeposited for the face amount of the check. Recovery fees, as applicable by state law, will be assessed on all returned checks and may be collected from your checking account, and/or billed directly to you. By presenting your check for payment for your transaction, you are acknowledging your acceptance of our Check Acceptance Policy. In the event your account does not have the authorized funds to be debited you will be charged a minimum of $25 per NSF transaction. This fee applies to both checks and ACH Debits.

DELINQUENT ACCOUNTS- All delinquent accounts (30 days or older) are subject to reasonable service charges and/or legal interest rates.

COLLECTION PROCEEDINGS- In the event your account is turned over to a collection agency for non-payment or other delinquency, you will be responsible for payment of any collection costs and/or attorney fees, in addition to the balance owed. Any account turned over to a collection agency forfeits any past special fees and/or discounts. Such special fees and/or discounts will be reversed and you will be responsible for payment of regular fees for procedures at the time of service. An additional fee of 40% of your total patient portion will be applied to cover collection costs. If your account is turned over to collections, you and your family will be dismissed as patients.

CANCELLATION/NO SHOW/TARDINESS- WE REQUIRE A 24 HR. NOTICE FOR ALL CANCELLED APPOINTMENTS- Individuals who fail to show for an appointment or call to reschedule within 24 hours of their
scheduled appointment are subject to a cancellation fee of $50.00 per hour based on the length of the missed appointment time. We do understand that situations arise, (such as a sick child) and we are very sympathetic of those situations. A TARDINESS of more than 15 minutes for an appointment WILL be rescheduled and may be subject to a missed appointment fee.

Office Policies Continued:

OUR OFFICE IS AN AMALGAM FREE OFFICE, which means we do not do any silver fillings. All of our fillings are done with resin material that is matched to the color of your teeth.

Most insurance companies will pay as though an amalgam filling was done because they are less expensive. For example, if the resin filling costs $100, the insurance company may pay for that same filling done as an amalgam (silver) filling which may be $80 they would then pay their percentage based on that lower fee. It is your responsibility as the patient to pay the difference. We do our best to estimate what your costs will be. We are always glad to answer any questions you may have.

ADULT SUPERVISION IS REQUIRED FOR ALL CHILDREN 13 and younger and all children who have medical conditions who are 17 and younger. Please check with the doctor or office staff regarding your childs health status with our office. If your child is left unattended, treatment will be stopped immediately and you will be charged for the cost of the appointment. If your child is over 14 years old and you must leave, you are required to provide a cell phone number and an additional emergency number. Please note; insurance does not allow us to bill them for treatment that was not completed due to patient non-compliance.

CELL PHONES MUST BE TURNED OFF while in the treatment areas. If we are unable to complete treatment due to cell phone use, you are still responsible for the cost of the appointment. Please note; insurance does not allow us to bill them for treatment that was not completed due to patient non-compliance.

DUPLICATION FEE- There may be a $25 duplication fee per family to copy all x-rays.

WE RESERVE THE RIGHT to update our office policies at any time. As a patient you agree to abide by
the policies set forth in our office.

I HAVE COMPLETELY READ AND UNDERSTAND THE CONTENTS OF THIS AGREEMENT. I AGREE TO COMPLY WITH ALL OFFICE POLICIES.

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.

I hereby give my consent for Stonegate Dental Care to:

1. Use and disclose protected health information about me to other healthcare providers who may be involved in my treatment directly or indirectly.

2. Obtain payment from third-party payors (i.e. insurance, financing companies, etc.)

With this consent, Stonegate Dental Care may contact me to discuss protected health information using the contact information provided.

I give my consent for Stonegate Dental Care to contact me through the following means: telephone, voicemail (if necessary), email and/or mail in reference to any item that will assist the practice in carrying out my patient care, such as appointment reminders, insurance items, account balances, patient statements and information pertaining to my clinical care.

In addition to the allowable disclosures described in the Notice of Privacy Practices, please specifically identify any individuals whom you authorize the disclosure of your protected health information. Without indicating by checking in the box to each individual question, personal protected information cannot be shared with anyone unless otherwise allowed by HIPAA rules. Please check all that apply:

I acknowledge that I have the right to review the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Stonegate Dental Care has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

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

Please Note: Stonegate Dental Care uses Dentrix as our dental software. Families with insurance coverage that extends to spouses and dependents cannot be separated from the subscriber within our system. As a result, financial information is combined for the family. Should you have any concerns regarding this practice, please speak to the front desk right away.