As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Dental Information

Medical Information

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Patient Screening

Within the past 24 hours, have you/they had any of the following symptoms?

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Primary Dental Insurance

Secondary Dental Insurance

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Informed Consent for General Dental Procedures

You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks and complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

It is very important that you provide your dentist with an accurate medical history before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled follow up appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Your mouth truly is connected to your health. The patient is an important part of the treatment team. It is important to report any problems or complications you are experiencing so they can be addressed by your dentist. It is equally important to report your medical conditions to us. Certain heart conditions may create a risk of serious or fatal complications. If you have a heart condition or heart murmur, high blood pressure, diabetes, pregnancy, or other health conditions, advise your dentist immediately so she/he can consult with physician if necessary.

Please inform us of all medication you are currently taking on top of any medications that you are allergic to. If you are taking oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes or if you are taking antibiotics.

As with all procedures and surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee you the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally. There are risk and limitations to all procedures. The practice of dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. Complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections.

Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:

1. Pain, swelling, and discomfort after treatment;
2. Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist;
3. Temporary, or, on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums and tongue along with possible loss of taste;
4. Damage to adjacent teeth, restorations or gums;
5. An altered bite in need of adjustment;
6. Possible deterioration of your condition which may result in tooth loss;
7. Jaw fracture;
8. Allergic reaction to anesthetic or medication;
9. A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed at a later point in time;
10. If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment;
11. Infection in need of medication, follow-up procedures or other treatment;
12. The need for replacement of restorations, implants or other appliances in the future;
13. Need for follow-up care and treatment, including surgery;
14. Prolonged numbness.

Specific Problem Examinations

In the event that a patient requests only a specific problem be addressed (i.e. broken tooth, pain in one area, etc.) this is considered a problem-focused evaluation. X-rays will be taken in this specific area only, and a complete comprehensive examination will not be done. The dentist cannot diagnose problems in other areas of the mouth. Any future treatment of other areas will require additional x-rays and a complete exam. You will not be considered a patient of record unless this examination is completed.

X-Rays

Our office takes the minimum x-rays to allow us to do a thorough exam for each patient. Modern dental x-ray equipment is extremely low dose radiation. Patient will receive a series of intra-oral x-rays. Diagnostic x-rays provide the dentists with valuable information about your teeth and supporting bone that cannot be evaluated otherwise. Without these x-rays, we cannot do a complete exam. We may also take photos of our patients as part of their permanent record. We will not release these photos to anyone without your permission.

Minor

We must receive written consent prior to performing any non-emergency procedures on a minor. Grandparents, step-parents, friends, relatives, etc. are not legally allowed to consent to dental procedures. Unless they have been given written consent by the patient or legal guardian, please do not send your child to an appointment alone or with someone else other than yourself unless you have filled out any necessary consent forms prior to the appointment. Otherwise, we may have no choice but to reschedule your child’s appointment to another day.

I certify that I read and write English and fully understand this consent. PLEASE ASK THE DOCTOR IF YOU HAVE ANY QUESTIONS CONCERNING THIS CONSENT FORM BEFORE SIGNING IT. By signing this form, I am freely giving my consent to allow and authorize the doctor and/or his/her associates to render any treatment deemed necessary, desirable and/or advisable to me, including the administration and/ or prescribing of any anesthetic and/ or medication.

Patient Acknowledgements, Agreements, and Disclaimer

Treatment Plan Estimates: Annapolis Dental Center prepares a Treatment Plan Estimate so that patients can understand the estimated costs of their recommended treatment prior to its start. The Treatment Plan Estimate is a good faith attempt to predict the cost of your treatment based on the facts known to Annapolis Dental Center when the estimate is made. As your treatment progresses, your dentist may determine in consultation with you that different or additional treatment is necessary and your financial responsibility may change.

If you have dental insurance, it is important to understand that your actual insurance benefits may differ from the benefits estimated in your Treatment Plan Estimate. Your Treatment Plan Estimate of insurance benefits is based on information provided by your insurance company and by you. It is an estimate and your insurance benefits may be higher or lower than estimated. In all cases, you are responsible for amounts not covered by your insurance, unless prohibited by law or contractual agreement. In all cases, we encourage patients with insurance to refer to their member handbooks or to call their plan administrators with any questions or concerns related to specific benefits.

Treatment Plans: All dental treatment plan presented to me is a breakdown of dental services that I need to maintain a healthy mouth. All pricing presented to me for such services are guaranteed for thirty (30) days from today.

Predetermination of Insurance Benefits: If you have insurance benefits, you may have the option to seek a Predetermination of Benefits before you proceed with any treatment. Predetermination of Benefits is a process whereby your insurance company or plan administrator tells you in advance of treatment what procedures may be covered by your insurance plan, the amount the insurance company may pay toward those procedures and the amount you may be required to pay. Requesting a Predetermination is like submitting a claim before the dental procedure or service has taken place. Because the Predetermination comes directly from your insurer or plan administrator, the risk of error as to your coverage is reduced. If your treatment includes extensive or complex services, such as bridges, crowns, dentures or periodontal work, a Predetermination may be particularly helpful to allow you to appropriately budget for the services or discuss any potential alternative treatment that may be available, if necessary.

The Predetermination of Benefits process give you useful information about what services may be covered. However, your insurer will inform you that a Predetermination of Benefits in not a guarantee of coverage. A Predetermination sets forth your expected benefits based on the information available to the insurer at the time the Predetermination is prepared. The Predetermination may not consider, for example, a prior claim submitted by another dentist for services provided to you, changes in your coverage that occur after the Predetermination is made but before the services actually are provided, or the insurance company’s subsequent opinion that a condition could have been treated by a less costly alternative to the service provided by your dentist.

The time it takes to receive a Predetermination from your insurance company or plan administrator can vary, from as few as two weeks to as many as eight weeks. The decision to seek a Predetermination of Benefits or to proceed with treatment immediately is your own, unless your plan requires otherwise. Please inform the Office Manager if you would like to request a Predetermination of Benefits from your insurer.

Insurance Estimate: For your convenience, we are happy to submit your dental claims and accept payment from your insurance company. Your insurance contract exists solely between you and your insurance carrier. We cannot be responsible for the limitations and exclusion determined by your participating insurance plan. With that being said, the insurance portion of the treatment plan is only an estimate and does NOT guarantee that your insurance carrier will pay their estimated portion. Your estimated portion will be due at the time of service. If your insurance carrier downgrades your services or pays a lesser amount according to your coverage then you, the patient will be responsible for the remaining balance due within thirty (30) days of receiving your Explanation of Benefits from your insurance provider. I authorize and request my insurance company pay directly to Annapolis Dental Center. I agree to be responsible for payment in full for all services not paid by insurance company for myself and/ or dependents.

Payments Accepted: Cash, Flex Spending, Credit Cards, and Care Credit. All children must be accompanied by a parent during services.

Complications: The risk of complications from medications used/prescribed with general dental treatment include, but are not limited to, drowsiness, lack of awareness and coordination, nausea, allergic reactions, etc. (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). It is not advisable to operate any motor vehicle or hazardous device while experiencing side effects of the medications we may prescribe.

Anesthetic: The use of local anesthetic is used for pain control during dental procedures. There are inherent risks and side effects. They include, but are not limited to: swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction, and altered sensation that may lead to self-injury. Partial or complete numbness may linger after the dental appointment. In rare cases, it can last for an extended time and potentially it can be permanent.

Medication: Any medications dispersed or prescribed are the patient’s responsibility to understand before taking. Particular attention should be given to possible allergic reactions, drug interactions with current medications and their specific side effects.

Guarantees: I accept and agree that there are risk and limitations to all procedures. I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding dental treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to allow Annapolis Dental Center to take x-rays and perform an examination on me today.

Notifications: It is the patient’s responsibility to notify the dentist and/or staff of Annapolis Dental Center within thirty (30) days of service if there is a problem. Through this notification, we will be able to act on the patient’s behalf. Attempts to correct a problem may occur at our office or a referral to another health care practitioner may be warranted. Any concerns past thirty (30) days will be the responsibility of the patient and any services provided will be an additional cost to the patient.

Appointment Cancellation: When an appointment is made, we set aside an allotted time for your procedure. In the event you are unable to give us 24 hour notice, there will be a $50.00 per person cancellation fee charged to your account from Mon. - Thurs. appointments and $75.00 per patient cancellation fee for Friday and Saturday appointments.

Delinquent Accounts: There is a $25.00 charge to your account for any returned check fee. We will submit all checks twice (2x) into your bank for payment. There is an interest of 5.25% per annum that will be charged on any unpaid balance over sixty (60) days. Any accounts over ninety (90) days delinquent will be sent to a collection agency and a collection fee of 35% of the balance will be charged to your account.

Refund Policy: You may discontinue treatment and request a refund from Annapolis Dental Center at any time. Annapolis Dental Center will refund any amount paid for treatment that you did not receive, except when Annapolis Dental Center’s policy for Interrupted Services. Patients requiring crown or bridge services may cancel treatment with no charge prior to natural teeth being prepared or altered for the prosthetic. Once tooth preparation occurs, patients are liable for the estimated full cost of the services even if they choose not to complete treatment.

Cash or Check Payment Refunds: Account Holder Refund Request - Upon receipt of a request for a refund, Annapolis Dental Center will confirm all payments by check have cleared the bank (may take up to 15 business days). Once the credit balance is confirmed, Annapolis Dental Center will issue a refund check within ten (10) business days. All refunds will be processed back to the original form of payment, except cash payments will be refunded by check.

I CERTIFY THAT I HAVE READ AND I UNDERSTAND THE ABOVE INFORMATION. I acknowledge that all my questions have been answered to my satisfaction. You have the right to accept or deny treatment before it is performed. The fee(s) for these services have been explained to me and I accept them as satisfactory. I understand the insurance estimate is not a guarantee of payment and that I am responsible for any difference in payment. By signing this form, I am freely giving my consent to authorize Dr. Dele including the administration and/or prescribing of any anesthetic agents and/or medications. Annapolis Dental Center reserves the right to change or cancel these terms and conditions at any time.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our changes will be paid by an insurance company.

A service charge of 5.25% per month on the unpaid balance will be charged on all accounts exceeding 45 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six (6) months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suite be instituted hereunder.

I grant permission to you or your assignee, to telephone, email, or text me to discuss this statement or my treatment.

I understand the above information and agree with its contents and agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges.

Insurance Authorization

Missed Appointments / Late Cancellations Policy

Thank you for selecting Annapolis Dental Center for your dental needs. We would like to take this opportunity to inform you of our practice’s Missed Appointments / Late Cancellations Policy.

Missed appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed appointments or appointments not cancelled within 24 hours. Effective October 1, 2019, the charge for missed appointments is $50.00 for a single missed appointment / late cancellation Monday through Thursday and $75.00 for a single missed appointment/ late cancellation Friday and Saturday. If you cannot make your appointment and our office is informed with advance notice of 24 hours or more, the appointment may be rescheduled without penalty. Excessive abuse of scheduled appointments may result in discharge from the practice.

If you have any questions about this policy, do not hesitate to ask.

I have read the above and understand that all missed appointment / late cancellation fees which I incur at Annapolis Dental Center are ultimately my responsibility. I authorize Annapolis Dental Center to process payments for missed appointment / late cancellation fees using the credit card information which I have provided.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.