Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.

Patient information

Last name
First name
Middle name
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Whom may we thank for this referral?

Primary Insurance

Last name
First name
Middle name
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Medical History

  • (Fosamax, Boniva)

Dental History

Financial Policy

Authorization and Consent

The above information is true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between Patient,, and Guaranteed Smiles to be necessary or advisable, including the use of local anesthesia and other medication as indicated. I understand that, regardless of insurance coverage, I am responsible for payment of service rendered and that a financial charge of $7.5 or 1.5% per month will be applied to accounts past due 30 days or more (this doesn’t apply in cases when insurance payment is pending). A processing fee of $25 will be added to my account balance in case of returned or stop payment checks. Delinquent accounts will be turned over to a collection agency or to Small claims Count.

I understand that Guaranteed Smiles requires a 24-hour notice for cancellations and that if I do not give the 24-hour notice or no-show appointments, I will be charged a cancellation fee that is within the allowance of my dental insurance. I understand that the office’s normal fee is $50 per hour that I am scheduled. I agree to pay for all my treatment rendered to me in accordance with my insurance plan and the financial agreements made with Guaranteed Smiles. I understand that the payment is due at the time services are rendered. I also understand that Guaranteed Smiles does not offer any payment plans other than Care Credit.

Payment

Guaranteed Smiles requires that Patient pays the estimated portion in full at the time of service. Special circumstances may indicate special arrangements. If Patient needs to set up a payment arrangement, Guaranteed Smiles offers a few different options, which can be discussed with the office manager. We accept Cash, Check, Visa, Mastercard, Capital One Financing and Care Credit.

Insurances

As a courtesy to our patients, Guaranteed Smiles will prepare and submit your insurance forms for reimbursement. We cannot bill or receive reimbursement from your insurance center unless you provide all of the necessary information. The correct insurance name, address, phone number, policy holder’s name and address, social security number, date of birth and group number are all needed. Please read and understand the following:

  • Your account balance is your responsibility whether your insurance company pays or not;
  • Your insurance policy is a contract between you and your insurance company, we are not party to that contract;
  • We recommend that you read your policy and have a basic understanding of what your insurance will and will not cover;
  • If your insurance company has not reimbursed our office within 60 days, you will be responsible for the entire portion of your account.

I have read, understand and agree to the above financial policy.

Signature of patient, parent or guardian Printed name Date