Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

Patient Information

Taylor Wagner Family Dentistry

2000 Fielders Road,
Jonesboro, AR 72401
(870) 972-6985

Patient Details( * mandatory to fill )

In an effort to provide you the best service possible, we ask you to fill out this form completely and review our office policies. 

  •  Yes
  •  No

If Yes, please request our insurance form at the front desk. 

  •  Yes
  •  No

 If yes, please request our guardian form at the front desk. 

Dental History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

 8. Are you sensitive to

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Loose
  •  Shifted
  •  Chipped
  •  Cracked
  •  Discolored
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Botox
  •  Veneers/Lumineers
  •  Invisalign
Medical History( * mandatory to fill )

These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition, but they are all associated with proper oral health care. Please answer each question, or circle YES or NO where applicable.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

(Please note that some recreational drugs taken within 24 hours of dental treatment could be fatal.)

  •  Penicillin
  •  Sulfa Drugs
  •  Aspirin
  •  Codeine
  •  Dairy
  •  Nuts
  •  Other
  •  Yes
  •  No
  •  Yes
  •  No

Please check if you have or have had any of the following

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

I certify that the above information is complete and accurate. If any changes occur to my health, I will advise the office immediately. I understand that I am responsible for full payment of each procedure at, or prior to, the time of treatment. I agree to give 24 hour notice if I change an appointment. I grant permission for Jonesboro Family Dental to take any necessary x-rays, administer anesthetics, and to employ such operative and technical procedures as necessary or advisable for the diagnosis and treatment of the above patient. All records, including photographs, are the property of the office.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.95.131.97 )

(If under 18, signature of parent/legal guardian)

Office Policy( * mandatory to fill )

Time Commitment

A scheduled appointment is a commitment of time between you and our doctor/hygienist. When an appointment is missed or cancelled on short notice that time is lost instead of being used by another patient. Our office usually confirms appointments 24 hours in advance. Please advise the office if you need to change your appointment at that time. We reserve the right to charge an office visit fee for appointments missed or cancelled without a 24 hours prior notice. Multiple missed appointments can result in dismissal from the practice.

Dental Insurance

We are happy to bill your dental insurance carriers, on your behalf at no charge. The benefits that are actually paid by insurance carriers vary widely from carrier to carrier and group to group, and depend primarily on the benefits negotiated and paid for by your employer, union, or other group with the insurance carrier. We can provide you with an approximate estimate of your coverage prior to treatment. However, we cannot guarantee the insurance payment as estimated.

Hence, any treatment rendered to you will be your financial responsibility irrespective of what your insurance pays. With your signature (below) you accept our policy and authorize Jonesboro Family Dental to 1) Bill your insurance carriers on your behalf; 2) release any information regarding treatment at this office to your insurance carrier(s); 3) authorize payment directly to Jonesboro Family Dental, any insurance benefits due to services rendered.

**Please inform the dental assistant if you have had x-rays taken at another dental office in the past five years. Insurance may not cover certain procedures if they have been done in another office. Jonesboro Family Dental is not responsible for any balances left by insurance due to treatment performed in another dental office, or otherwise.

Payment Options

For your convenience, we accept cash, check, and all major credit cards (Visa, MasterCard, American Express, and Discover). Furthermore, our office offers applications for easy to use financing programs, the most popular being CareCredit, which offers up to 18 months interest free** financing with no penalty for early payoff. Financing is subject to application approval.**

Non-payment of services/Collection Policies

By signing below, I understand that any amounts not paid by insurance for any reason are my responsibility to pay. Any past due accounts turned over to a collection agency will be subject to additional collection fees, which are a percentage of my balance due, up to 40%. By signing below, I agree that any collection or servicing agency or agencies retained to collect any money due Jonesboro Family Dental may contact me by telephone or text message at any number given by me or associated with my account, including but not limited to cellular/wireless numbers which may result in my incurring fees for the call or text message. I understand, acknowledge and agree that the collectors may contact me by autodialing devices and through pre-recorded messages, artificial voice message or voice mail messages. I further agree that the collectors may contact me using e-mail at any e-mail address I provide or is otherwise associated with my account.

Notice of Privacy Practices

Our office obeys federal and state law regarding the privacy of your health information. With your signature below you acknowledge the receipt of our office's Notice of Privacy Practices as well as the policies listed above.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.95.131.97 )

I would like the following people to be given any access to my health information, including but not limited to health history, appointments and diagnoses.

Insurance Information page and Legal Guardian/Spouse Page( * mandatory to fill )

You may skip this page if you are over 18 and do not have any insurance coverage.

Spouse Information (if on their Insurance) or Legal Guardian Information (if patient under 18)

  •  Yes
  •  No

INSURANCE INFORMATION

Primary Dental Insurance

Secondary Dental Insurance (if applicable)

(Please click below to draw/upload sign)
(Your IP Address : IP:3.95.131.97 )
Copyright ©2019
Your browser doesn't support signing