Female Patients - Please answer the following:

ALLERGIES

DENTAL CONDITIONS

Yes No	Has the patient ever been to the dentist before
Yes No	Is the patient's water fluoridated
Yes No	Does the patient take or use a fluoride supplement
Yes No	Does the patient use fluoridated toothpaste or mouth rinse
Yes No	Is the patient apprehensive about dental/orthodontic treatment
Yes No	Has the patient had problems with previous dental/orthodontic treatment
Yes No	Has the patient ever had braces
Yes No	Does parent/guardian or the patient want more information about braces
Yes No	If the patient plays sports does he/she wear a mouthguard
Yes No	Does the patient gag easily
Yes No	Do the patient's gums bleed easily
Yes No	Does the patient have teeth sensitive to hot or cold
Yes No	Does the patient clench or grind their teeth

 

 

APPOINTMENT CANCELLATIONS

As a courtesy, we make every effort to confirm your appointment one day in advance. However, it should be noted it is your responsibility to keep all appointments. We request a MINIMUM OF 24 HOURS to change or cancel an appointment. A fee may be incurred for all failed or late cancellations. For more than two failed or cancelled appointments you may be placed on same day only appointment basis.

DENTAL INSURANCE

If you have insurance coverage, our staff as a courtesy does their best to determine a proper ESTIMATE for you. Due to the many insurance companies and plans we cannot always predict the actual payments your insurance carrier will make. You are required to make payment of your full estimated responsibility upon services rendered. After payments are received from your insurance carrier, you may be required to make additional payments, have a credit issued to your account for future services or may be eligible for a refund. By signing this form, I hereby authorize and direct payment of dental benefits from my insurance company to New England Smile, LLC.

If you have Masshealth coverage, please be aware if you have a lapse in your coverage, or a procedure is denied, you are responsible for any out of pocket expenses that incur. You are responsible for understanding the benefits provided to you.

AUTHORIZATION AND RELEASE

I certify that the information provided is accurate and complete to the best of my knowledge. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child during the period of such dental care to third party payers and/or health practitioners.

INFORMATION REGARDING FILLINGS

Please be advised we no longer use silver (amalgam) fillings on primary (baby) teeth due to substantial improvement in composite/resin (white) filling materials. These new materials have been found to perform better than amalgam on primary teeth. We may still recommend, on occasion, silver (amalgam) fillings in certain cases for permanent (adult) molars or as a request of the parent.

Please be aware that some insurance plans pay differently on composite restorations and your co-payment may be higher. The balance is the patient’s responsibility.

Please contact your insurance if you have any concerns. If finances are a concern, we can submit a pre-treatment estimate with your insurance company for the treatment recommended. We will be happy to assist you with that request.


     

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

   

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SOCIAL MEDIA CONSENT

We like to show off all the fun and great things that happen at New England Smile. Often times we do this on social media in the form of photographs or videos and include our patients and their families. Please let us know if we have your permission to post any photographs or videos that may include you or your child on various New England Smile social media sites. These may include (but are not limited to) Facebook, Google+, Twitter, and Instagram.

I consent to New England Smile social media usage

I do not consent to social media usage

   

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ELECTRONIC COMMUNICATIONS ENCRYPTION WAIVER

When communicating via electronic media (e.g. email) HIPAA standards require us to utilize encryption technology for your privacy. To keep electronic communications private, we utilize third party encryption methods that typically require a password for viewing. If you prefer to avoid encrypting any emails that may contain private information and opt out of data encryption, please fill out the form below. By opting out of electronic encryption all electronic communications will be sent without password protection.
 

I wish to opt out of electronic encryption

Yes No