Gravity Form

Dentist in Hanover, PA

Dr. Werleman & Associates

COSMETICS & FAMILY DENTISTRY

PERSONAL INFORMATION

Patient Name(Required)
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Parent or Guardian (if pt is under 18)(Required)
Relationship to Patient(Required)
Address(Required)
Please check all that apply:(Required)
(Required)
(Required)
State(Required)
Name of person responsible for this account (must sign below)(Required)
Address(Required)
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Employer Name(Required)
Please check your co-pay choice(Required)
How did you hear about us?(Required)

DENTAL INSURANCE INFORMATION

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Insured's Address if different from above(Required)
Ins. Address(Required)

We only use tooth colored (resin) fillings in our office and will not replace Silver/Mercury containing fillings in our patient’s teeth. Should your insurance co. provide a benefit for white filling based on the equivalent of a Silver/Mercury filling, you are still responsible for a difference.

CONSENT-PLEASE READ BEFORE SIGNING

Please be advised- A $50 broken appointment fee will be assessed for any appointment "No Show" or cancelled/rescheduled with less than a 48 hour notice.(Required)
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Please check any of following which you had, or currently have:(Required)
Allergies(Required)

HOSPITALIZATION

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CONSENT- PLEASE READ BEFORE SIGNING

I undersigned hereby authorize the Doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of patient’s needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents antibodies a certain risk.
I also give full permission for dental services to be rendered upon my child under the age of 18 if I decide not to be present for my child’s scheduled appointment.
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DENTAL &HEALTH HISTORY

Patient Name(Required)
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Do you have to take Antibiotics before dental treatment?(Required)
Are you having problems/discomfort now?(Required)
Do you wear dentures?(Required)
Do you wear partials?(Required)
Would you like to have them to fit tighter?(Required)
Are you fearful about dental treatment?(Required)
Have you had any gum treatment?(Required)
Do your gums?(Required)
Are your teeth sensitive to(Required)
Do you grind your teeth?(Required)
Do you wake up with sore teeth?(Required)
Do you have any of the following?(Required)
Have you worn braces?(Required)
Are you happy with the results?(Required)
Would you like your teeth(Required)
Please rank 1-4 the order in which the following would KEEP you from having dental treatment done. (1 being the most important)(Required)
Fear of pain
Lack of Concern
Cost of Treatment
Missing time from work
 
Do you have any current health problems?(Required)
Are you currently taking any over the counter medications?(Required)
Are you taking any herbal medications?(Required)
Have you ever taken FenPhen?(Required)
Redux?(Required)
If yes to either of these. Have you had an EKG/Echocardiogram??(Required)
Are you taking vitamin supplements?(Required)
Do you smoke?(Required)
Use chewing tobacco/snuff?(Required)
For female patient, Is it possible that you may be pregnant?(Required)
Are you taking any oral birth control pills?(Required)

2023 FINANCIAL POLICY

We accept Cash, Visa, MasterCard, American Express, Discover, Money Orders, Personal Checks or CareCredit.

DENTAL INSURANCE

• The range of dental benefits depends solely on what your employer wishes to purchase. As a result, we ESTIMATE your initial responsibility based upon the information available to us. There are instances in which insurance covers more than originally estimated. In this case, your account with reflect the proper credit and you will be refunded.
• Some plans base the amount of benefits on a schedule of fees arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage than the reimbursement level indicated in your dental plan. For example, if your plan states that they will pay 80% of the cost of a specific treatment, it means 80% of the fee arbitrarily determined by the company and not the actual fee charged by the office.
• We only use tooth colored (resin) fillings in our office and will not place any Silver/Mercury fillings in our patient’s teeth. Should your insurance provide a downgraded benefit to Silver/Mercury fillings for the resin fillings completed, you are responsible to pay the difference.
• We only use ceramic or porcelain crowns that are made in our office. Some insurances will downgrade the benefit to an all-metal crown. Should this happen, you are responsible to pay the difference.

CANCELLATION POLICY

We require a 48-hour notice to change an appointment. We do understand that unforeseen circumstances may arise, resulting in the need to change an appointment without a 48-hour notice. We reserve the right to charge a $50 fee for all missed appointments or appointments changed with less than a 48-hour notice.

TREATMENT DEPOSIT

To reserve a spot for treatment, we will now be requiring a 50% deposit of the total cost for treatment. This does not include your routine 6-month checkup and exam. Treatment estimates and financial agreements will be presented when scheduling your appointment.
A collection charge of 33% will be added if your account is turned over to collections.
If a credit card is used to process your payment, you will be charged a 3% processing fee on any refunds

CONSENT- PLEASE READ BEFORE SIGNING

I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I understand that ESTIMATED FEES given by the office are based on information from my insurance company. I have read and understand all of the information above.
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Print(Required)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

A copy of our privacy practices will be supplied at your request. Otherwise the notice is posted in our office. You may refuse to sign this acknowledgement.
Consent(Required)
Name of authorize person's who may discuss my dental treatment.(Required)
(Required)
(Required)

Patient Name(Required)
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FOR OFFICE USE ONLY

We attempted to obtain written authorization of receipt of our Notice of Privacy Practices and the patient’s authorization for release of any dental information to an authorized party due to:
For Office use only(Required)

SMILE EVALUATION

Have you ever been told your smile improvement options?(Required)
Would you like your teeth to be straighter?(Required)
Are you interested in permanent replacement of any missing teeth?(Required)

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