To assist us in serving you, please complete the following form. The information provided is important to your professional dental health. If there have been any changes in your health, please let us know. If you have any questions, please feel free to ask us, we will be happy to help you complete it.

Patients are required to pay in full at the time of service. Cash, Check, Visa, MasterCard, Discover, American Express or CareCredit are accepted forms of payment.

Kirkwood Dental Office Policies & HIPAA

Thank you for choosing Kirkwood Dental Associates, P.A. ~ KDA as your dental provider. We are committed to the latest in technical advances delivered with comfort and care. Below is some important information which we would like to share. All patients must complete and sign this form, prior to receiving services.

Patient Name (PLEASE PRINT):

How do you want to be addressed when summoned from the reception area (CHOOSE ONE):
First Name Only Proper Surname Other:

CANCELLED / MISSED APPOINTMENT POLICY:
When you schedule a dental appointment, Kirkwood Dental Associates, P.A. reserves time in the schedule that is no longer available to other patients. As the time is reserved especially for you, if you are unable to keep your commitment please give us 48 hours notice so that other patients will have prompt access to dental care. KDA reserves the right to charge a $50 broken appointment fee for appointments that are missed and/or cancelled with less than two (2) business days notice. In the event that multiple appointments are missed and/or cancelled with less than two (2) business days notice, the patient may be placed on a same day only list. At all times, Kirkwood Dental Associates, P.A. reserves the right to dismiss the patient(s). Arriving more than 10 minutes after your scheduled appointment time may result in the appointment being rescheduled.

HIPAA Consent:
I have received a copy of KDA Notice of Privacy Practices from the practices website when I completed my initial paperwork. With my consent, KDA may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operation (TPO). I also authorize KDA to call my home, cell, or designated location, send email and/or text messages, and leave a message on voicemail, or in person, in reference to any items that assist KDA in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results, among others. With this consent, KDA may mail to my home, cell, or other designated location any items that assist the practice in carrying out TPO, such as patient statements.

Please list the persons with whom we may discuss your information, if needed.

Name:
Phone #:
Relationship to the patient:

Name:
Phone #:
Relationship to the patient:

REMAIN IN EFFECT (CHOOSE ONE):
Until

CHOOSE DATE
INITIALS REQUIRED
OR
Indefinitely

INITIALS REQUIRED

COMMUNICATIONS:
As a service to our patients, we provide courtesy appointments and re-care reminder messages, and other important messages, such as office closures, by using text messages. We also may send text messages notifying you of promotions our practice may offer from time to time. By providing your cellphone number, you consent to receiving text message reminders and notifications at this number. You may opt out of receiving text messages by texting STOP in reply to the message at any time.

Mobile Phone #:
Phone Calls ONLY, no Text Option
INITIALS REQUIRED

We may also provide these messages by e-mail. By providing your e-mail address, you consent to receiving e-mails.

E-mail Address:

How would you like to receive your bill, if one pertains to you or your family?
Email Mail

I HAVE READ ALL OF THE POLICIES ABOVE AND AGREE TO ABIDE BY THE TERMS AND CONDITIONS AS STATED IN EACH.

Signature of Patient (Parent/Guardian if Minor) / Responsible Party
Date

Signature of Kirkwood Dental Associates, P.A. Employee ______________________________________________
Date:________________

Patient Information & Medical History

Today's Date
Sex
Male Female

Legal Name
Age

Preferred Name

Date of Birth
SSN#

Address

City
State
Zip

Billing Address (if different)

City
State
Zip

Divorced Married Single Widowed

Home Phone
Cell Phone

Spouse/Partner's Name

Spouse/Partner's phone

Emergency contact name & phone

Appointment Confirmation method (Please check one)

Phone call Text message Email

Do you have Dental Insurance
Yes No

Primary Dental Insurance

Insurance Co. Name

Group #
Subscriber ID

Subscriber's Name

Relationship
Employer

Date of Birth
SSN#

Secondary Dental Insurance (if applicable)

Insurance Co. Name

Group #
Subscriber ID

Subscriber's Name

Relationship
Employer

Date of Birth
SSN#

How would you like to receive your bills? (Please check one)
Email Mail

Pharmacy name

Address

Phone

Physician & number

Cardiologist & number

Yes No

Are you apprehensive about dental treatment?

Are you dissatisfied with the appearance of your teeth?

Does food catch between your teeth?

Have you had problems with previous dental treatments?

Do you have difficulty chewing your food?

How often do you brush?

How often do you floss?

Do you avoid brushing any part of your mouth because of pain?

Do your gums:
Bleed easily Bleed when you brush Bleed when you floss Feel swollen or tender

Are your teeth sensitive?
Cold Hot Sweets

Referred to us by

Previous Dentist & Number

Date of last visit

Yes No

Do you clench or grind your teeth frequently?

Do you have sore jaw muscles or headaches upon awakening in the morning?

Do you take fluoride supplements?

Do you wear dentures?

Does it hurt when you chew?

Have you ever been diagnosed with TMD temporomandibular (jaw) disorder?

Have you ever noticed slow healing sore in or around your mouth?

Have you had trauma in the jaw?

Do you have pain in the face, cheeks, jaw, joints, throat, or temples?

Yes No

Are you taking blood thinners?

Have you ever been treated for low bone density or osteoporosis?

Do you require antibiotic premedication for dental appointments?
(heart valve, joint replacement, etc.)

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

Aspirin, Acetaminophen, or Ibuprofen

Barbiturates, sedative, or sleeping pills

Codeine, Demerol, or other narcotics

Latex

Local anesthetics (Novocaine)

Penicillin or Amoxicillin

Reaction to metals

Sulfa Drugs

Foods such as Bananas or Peanuts

Other

Other (please check all that apply)

Yes No

Cancer Chemotherapy Radiation

Diabetes

Epilepsy, Seizures, or fainting Spells

Frequent or severe headaches

HIV Positive/AIDS

Hepatitis, jaundice, or liver trouble

Persistent cough or swollen glands

Respiratory diseases

Sexually transmitted disease

Stroke(s)

Thyroid Problems

Tuberculosis

Glaucoma

Please check if you:

Drink Alcohol Smoke Have a history of substance abuse

Please check if you are:

Pregnant Taking birth control or other hormones Nursing

Expecting due date

ONLY CHECK BELOW IF YES

Heart problems

Chest Pain Heart Murmur Heart Valve Problem High Blood Pressure Low Blood Pressure Pacemaker Rheumatic Fever Shortness of Breath Taking Heart Medication Artificial Valve

Blood Problems

Abnormal Bleeding Anemia Easy Bruising Hemophilia Transfusions Frequent Nosebleeds

Allergy Problems

Hay Fever Sinus Problems Skin Rashes Taking Allergy Medication Asthma

Bone or Joint Problems

Arthritis Back or Neck Pain Joint Replacement (i.e. total hip, pins, or implants) Osteoporosis

Do you have any other disease, condition, or disability not listed?

Please list any surgeries and approximate date.

Please list any prescriptions medications or over the counter drugs you may take, and the condition it is taken for.

I have read all the information and have completed the above information. I certify that this information is true and correct to the best of knowledge. I will notify you of any changes in my health status or any of the above information. I hereby authorize the release of information relating to my insurance claims and give my permission for my physician to be contacted if necessary. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.

Patient Signature (or Guardian of Minor)
Date

Kirkwood Dental Financial Responsibility

Patient Name (PLEASE PRINT):

For all patients, it is necessary to have an easily understood financial responsibility policy whether or not there is dental insurance coverage involved. If there is dental insurance, as a result of the many different and confusing insurance company reimbursement policies, it is important for patients to understand how Kirkwood Dental Associates, P.A. ~ KDA will assist you with your insurance. The treatment recommended is based on the patient's need and not by what any insurance company will cover. Your treatment should not be governed by your insurance contract, which is a contract between you and your insurance company. While we would be happy to answer questions to help you understand your insurance coverage, your best resource would be to check with your insurance carrier directly. All patients/responsible parties must sign this form prior to being treated.

It is necessary for you to provide the office with complete insurance information for all carriers with whom you are insured at the time of service. Prior to or at each scheduled appointment, we need you to provide your current insurance information for our files, to ensure claim(s) can be accurately submitted. It is your responsibility to inform KDA of any insurance changes (i.e. employer, insurance plan, etc.) or any personal changes (i.e. name, address, phone number, etc.) that will impact your insurance coverage.

As a service to our patients, we will submit your insurance claim to your primary insurance company. KDA will provide all the information necessary to help you receive maximum benefit from your insurance coverage. However, it is the responsibility of the patient/insured to determine and understand the details, restrictions, and benefit limitations of your particular policy. KDA is not responsible for whether or not a service performed is a covered benefit and therefore will not assume responsibility for the insurance company's refusal to pay a claim. PLEASE BE AWARE MOST INSURANCE PLANS HAVE A MAXIMUM AMOUNT OF BENEFITS THAT THEY WILL PAY PER PLAN YEAR.

If a claim is denied, we will research why the rejection occurred and either resubmit to insurance or bill you the appropriate balance. If the claim is denied a second time, any appropriate balance becomes the responsibility of the Patient/Responsible Party and should be paid to us directly. You may then contact your insurance company for further information.

If the patient has coverage with an additional insurance company, we will submit all secondary claims directly, along with a copy of the Explanation of Benefits from the primary insurance. If the primary insurance payment is sent to the insured, the insured must provide the Explanation of Benefits to KDA in order for additional insurance to be submitted. Otherwise, submission for additional Insurance is the responsibility of the patient/insured. As coordination of benefits is unpredictable, payment from the additional insurance coverage may be paid directly to the insured.

Insurance is a patient's benefit designed to assist in the financial obligation for services rendered to the patient by the dental providers of KDA. The patient is the one receiving the dental service and therefore the Patient/Responsible Party is ultimately responsible for payment for all charges on the account regardless of any insurance coverage.

At, or prior to the time of service, KDA will estimate the anticipated insurance payment and will collect from the Patient/Responsible Party the estimated balance due along with any deductible which may apply. KDA cannot guarantee any estimated coverage. After the primary insurance payment is received, the Patient/Responsible Party will be billed for any difference between the estimated balance due and the actual balance due. Upon receipt of the statement, the remaining patient balance must be paid in full within thirty (30) days, unless a signed financial agreement has been approved. If the insurance payment is greater than what was anticipated, we will either refund the amount to the Patient/Responsible Party or leave the credit balance on the patient's account to be applied toward future treatment.

In the event that the patient does not have insurance coverage or the insurance company sends the insurance payment directly to the insured, CHARGES FOR SERVICES ARE DUE AND PAYABLE IN FULL AT THE TIME SERVICES ARE RENDERED, unless a signed financial agreement has been approved.

For your convenience, we accept cash, check, Visa, Mastercard, Discover, and American Express (subject to change at the discretion of KDA). Dental payment plans through third party lenders, are also an option, upon application and approval from the lender. KDA reserves the right to charge the account a fee for any check returned unpaid by the bank. If a check is returned unpaid by the bank, your personal checks will no longer be accepted.

Insurance benefits are estimates only. I understand the insurance company makes the final determination of payment and eligibility and they may pay less than the actual bill for services and less than what may have been predetermined by them. I understand that I am responsible for any co-payments and deductibles, along with any payment for procedures that my insurance company does not cover. I am also responsible for any balance due because of insurance claims not paid within 60 days of service. I authorize KDA to release any information, including diagnosis and records of treatment rendered during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to KDA, insurance benefits, otherwise payable to me.

I understand that KDA reserves the right to charge a monthly billing fee or finance charge and to use a Collection Agency for the collection of my account and will charge my account any collection fees involved. If KDA initiates legal action to collect amounts due, I agree to pay pre and post judgment interest, court costs, and attorney's fees that may apply, as allowed by the law and the court. I further understand that if my account is sent to collections, all scheduled appointments will be cancelled, until the account is paid in full. At all times, KDA reserves the right to dismiss patient(s) from the practice for the below responsible party.

I have read and understand the above, and I agree to be responsible for payment of all services rendered and any billing/collection fees accumulated on the patient's account.

Name of Patient (Parent/Guardian if Minor) / Responsible Party (PLEASE PRINT)
Social Security Number of Responsible Party

Signature of Patient (Parent/Guardian if Minor) / Responsible Party
Date

Signature of Kirkwood Dental Associates, P.A. ______________________________________________
Date:________________

Please confirm you are human before submitting the form.