Health History And Registration Form

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HEATH HISTORY & REGISTRATION

PATIENT INFORMATION

PATIENT'S NAME Last First Middle Initial Sex: M F Birthdate Age

Soc. Sec # If Patient is a Minor, give Parent's or Guardian's Name Today's Date

Who may we thank for referring you to our office? Reason for this visit?

Driver's License# State E-Mail Address

If a Child, Parent's Name Driver's License#

Mailing Address City State Zip

Phone - Home Business Cell Marital Status

Patient's Employer Business Address

Present Position How long held?

Spouse's Name Spouse's SSN#

Spouse's Employer Business Address Bus Phone

Present Position How long held? Spouse's Date of Birth

INSURANCE INFORMATION

Who will pay this account? Do you have insurance? YES NO (select one)

Name of Insurance Group No.

Who is the Subscriber? Subscriber's Birthdate

Subscriber's SSN# Employer

Select Method of Payment: Cash Check Credit Card CareCredit

My signature authorizes release of my medical information and x-rays; and authorizes payment directly to Max S. Breazeal, D.D.S. upon completion of treatment.

Signature of Responsible Party Date Relationship to Patient

OFFICE POLICY

INSURANCE

I UNDERSTAND THAT DR. BREAZEAL IS AN OUT OF NETWORK PROVIDER AND THAT I AM RESPONSIBLE FOR MY INSURANCE DEDUCTIBLE AND CO-PAYS, SET OUT BY MY INSURANCE COMPANY, ON THE DAY SERVICES ARE RENDERED. I also understand that my dental insurance is a contract between me and the insurance company, not between the insurance company and Dr. Breazeal. I UNDERSTAND THAT AS A COURTESY TO ME, DR. BREAZEAL'S OFFICE WILL FILE MY INSURANCE, HOWEVER I AM STILL RESPONSIBLE FOR ALL DENTAL CHARGES. If the insurance company has not paid their portion within 30 days of being properly billed, as mandated by the insurance Commissioner of the State of Tennessee, I understand that the balance will become due and payable from me.

DELINQUENT ACCOUNTS

I understand that payment is due at the time services are rendered unless payment arrangements have been made and approved in advance. All unpaid balances will be subject to a finance charge after 90 days of 1.5% per month, which is an annual percentage rate of 14%. In the event we are forced to submit a delinquent account to a collection agency, I agree to reimburse any fees of any collection agency, which will be 33% of the debt, and all costs, and expenses, including reasonably attorney's fees we incur in such collection efforts, which will be added at the time the account is sent for collection.

FAILED APPOINTMENT CHARGE

I understand that as a courtesy to me, I will either be called, emailed or texted the day before the appointment to confirm. We are reserving that time exclusively for you, if for any reason you can no longer make your appointment please call within 24 hours to cancel or reschedule. Otherwise, you will be charged for a failed appointment fee. If I fail my appointment without giving 24 hrs notice a $25 FAILED APPOINTMENT CHARGE will be added to my account. If the appointment was for two hrs, there will be a charge for $50 added to my account.

RETURNED CHECKS

All returned checks are subject to a $50 service fee. Any returned check must be resolved before any future appointments can be arranged.

I understand that responsibility for payment for dental services provided for my dependent or myself is MINE, due and payable at the time services are rendered.

PATIENT Signature Date Relationship to Patient

YES NO

Do you snore OR have you ever been told you snore?

Have you been diagnosed with sleep apnea?

Do you wear a C-PAP or have you in the past or have you been told to?

Have you had a sleep study or been told to get a sleep study?

LIST ALL MEDICATIONS TAKEN DAILY
(Prescribed and Over the Counter)

Is there any other Medical or Dental Information that you feel I should know about?

FAMILY PHYSICIAN

PHYSICIAN PHONE NO.

Have you ever had any serious illness not listed above?
YES NO If yes, please explain

Patient Signature Date

Patient Validation: