Name of previous dentist:
______________________________________________________ How long
since your last dental visit?
_____________________________________________ Do you have any
concerns about your teeth currently?
_______________________________ Do you clench or grind your teeth?
_________ How do you feel about your teeth and gums ?
______________________________________
How did you first hear about Belmar Smiles and/or Dr. VerSchave?
Another member of my family comes here. (Name:
_____________________________________________) Another
doctor/dentist referred me. (Name:
__________________________________________________) A friend
referred me. (Name:
____________________________________________________________) I did
a search on the internet and found the website. Other:
_____________________
Belmar Smiles is fully committed to providing the best dental
care possible, independent of contracted dental benefits. We will
always assist our patients at the time of service in completing the
necessary paperwork to ensure that you receive the maximum benefits
allowed by your dental benefit provider. Third-party financing
options are also available, and we will be pleased to provide the
necessary forms, and to assist you with their completion. Please
note: Your dental care insurance carrier may pay less than the
actual bill for our services. You are financially responsible for
payments in full for any treatment you receive from us, regardless
of payment decisions made by your dental care insurance
carrier.
By signing this statement, I am revoking all previous agreements
to the contrary and agree to be responsible for payment of services
not paid in whole or in part by my dental care payer. I also assign
all insurance benefits to the doctor.
Part 4: Dental History
Dr. VerSchave and her staff and/or associates
Part 6: Emergency Contact Information
Part 7: Permission to Treat You
The undersigned hereby authorizes Dr. VerSchave and her staff
and/or associates (collectively “Doctor”) to take
x-rays/radiographs, study models, photographs, or any other
diagnostic aids deemed appropriate by Doctor to make a thorough
diagnosis of the patient’s dental needs. I authorize Doctor to
perform any and all forms of treatment, medication, and therapy,
that may be indicated. I also understand that the use of anesthetic
agents embodies a certain risk. In addition, I authorize release of
any information concerning my (or my child’s) health care, advice
and treatment provided for the purpose of evaluating and
administering claims for insurance benefits. I authorize release of
any information concerning my (or my child’s) healthcare, advice
and treatment to another dentist. I request and authorize Doctor to
do whatever he/she deems advisable if any unforeseen condition
arises in the course of these designated operations and/or
procedures in addition to or different from those now contemplated.
I consent to the aforementioned treatment after having been advised
of the risks, advantages and disadvantages of the treatments and
the consequences if this treatment were withheld. I realize that in
spite of the possible complications and risks, my contemplated
surgery/treatment is necessary and desired by me. I am aware that
the practice of dentistry and surgery is not an exact science and I
acknowledge that no guarantees have been made to me concerning the
results of the operation and/or procedures). Further, I attest that
all of the medical and dental information I have provided is true
to the best of my knowledge. Signed
____________________________________________________________ Date
______________________________
New-Patient-Form-2010.pdf
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