Columbia Laser Dental

16415 SE 15TH Street, Ste 105

Vancouver, WA 98683

(360) 953-8135

Welcome To Our Practice. Please take a moment to enter or update your information to help ensure the quality of your care is excellent. Your information is kept confidential.

Patient Information

Date Family Status:Married Single Child Other

Patient’s Name: Last First MI Preferred Name

DOB: Gender: S.S.# / /

Address: Phone #’s: Home

City, State

Zip Code

Cellular

E-Mail:

Whom may we thank for referring you to our practice? Name of Individual, Office or other source such as Val Pak

Employers Name Phone#:

and Address:

Primary Insurance Information

Insurance Plan Name:

Insurance Address: Phone#:

Name of Insured: Last First MI Preferred Name

DOB: ID#: Group #:

Patient’s relationship to Insured: Self Spouse Child Other

Employers Name:

and Address: Phone#:

Do you have a Secondary Ins y n if so; you must request to fill out an additional form.)

Responsible Party Information

Responsible Party Name: Last First MI Mr./Ms./Mrs./etc

Address: Phone #’s: Home

Cellular

E-Mail:

Financial Policy and Consent for Services

Our office wants all our patients to be able to comfortablyafford dental care. We will gladly discuss our payment options with you before beginning treatment. We proudly offer the following financial policies so that our patients can have the opportunity to decide which payment option best suits your needs:

Dental Insurances: Our office will gladly work with you to help get the maximum benefit available to you. Most dental insurances do not cover 100% treatment costs. Therefore, you will be asked to pay your deductible and co-payment on the day services are rendered. We are happy to file the forms necessary to assure you receive the full benefit of your dental insurance. We will gladly estimate your coverage; however many variablesexist from carrier to carrier (i.e.: Deductibles, annual maximums, allowable fee limitations, non-coverage procedures and other restrictions).Therefore, we cannot guarantee any estimated charges. Because your insurance company is an agreement between you and the insurance company, ultimately you are responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits from your insurance company. Allowable charges for services not covered by your insurance plan are your responsibility. Accounts not paid in full after 60 days from the date of service will be subject to late fees and accrue interest charges of 1.5% monthly (18%APR). If for some reason your insurance company has not paid their portion within 60 days from the start of treatment, you are responsible for payment at that time.

Senior Citizens: As a courtesy to anyone 65years or older, we will gladly discount your fee by 5% if services are paid at the time of treatment.

Payment Options:

INSURED AND NON INSURED PATIENTS PAYMENT OPTIONS: Payment is expected in full the day of treatment.

We accept the following:

1)Cash/TeleCheck:Our office accepts both Cash and TeleCheck.

Personal Insurance Deductibles and/or Co-Payments are required at the time of service

2)Credit Card: Our office accepts Visa, MasterCard and Discover.

3)Outside Financing: Payment Plans are available with CareCredit.

CANCELLATION POLICY: Please notify us at least 48 hours in advance if you are unable to keep this appointment. This time has been reserved exclusively for you. A charge may be made for missed appointments of $50.00.

Signature: ______Date: ______

Privacy Practice Acknowledgement

I, ______, hereby acknowledge that I have been offered my own personal copy of Columbia Laser DentistryNotice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature: ______Date: ______

Medical and Dental History Form

Patient’s Name: Last First MI Preferred Name

Height: Weight: DOB: Gender: Title: Mr./Ms./Mrs./etc

Please take a moment to let us know about your medical and dental history so we may serve you more effectively.

1)Would you consider yourself to be in fairly good health? Y N

2)Within the past 5 yrs, have there been any changes in your general health? Y N

3) Have you been hospitalized due to surgery or illness? Y N

4)What is the approximate date of your last medical exam?______

5)What is the name and phone# of your Primary Care Physician? ______

6)Are you currently under the care of a physician due to a specific condition? Y N

7)Are you currently taking any prescription or non-prescription medications? Y N

8)Any other conditions, diseases, etc., that we should be aware of?Y N if yes, please list______

9)Please describe any current medical treatment, impending surgery or other treatment that may possibly affect your dental treatment:______

10)List Medications, Herbal Supplements and /or Vitamins taken within the last 2 yrs:______

HAVE YOU EVER HAD ANY OF THE FOLLOWING?

1)Allergic reaction to (Please Check)

Aspirin
Ibuprofen
Acetaminophen
Penicillin
Erythromycin
Tetracycline
Codeine
Local Anesthetic
Other______
Fluoride
Metals ______
Latex

2)Heart Problems

3)Heart murmur

4)Rheumatic Fever

5)Scarlet Fever

6)High blood pressure

7)Low blood pressure

8)Stroke

9)Artificial prosthesis (heart valve or joints)

10)Anemia or other blood disorder

11)Prolonged bleeding due to a slight cut

12)Emphysema

13)Tuberculosis

14)Asthma

15)Sinus problems

16)Kidney disease

17)Liver disease

18)Jaundice

19)Thyroid or Parathyroid disease

20)Hormone deficiency

21)High cholesterol

22)Diabetes

23)Ulcers ______

24)Digestive Disorders

25)Arthritis

26)Glaucoma

27)Contact lenses/Glasses

28)Head or Neck injuries

29)Epilepsy, convulsion or seizures

30)Viral infections

31)Any lumps or swelling in the mouth

32)Hives, skin rash, hay fever

33)Venereal disease

34)Hepatitis (type______)

35)HIV/AIDS

36)Tumor, Abnormal growth

37)Radiation Therapy

38)Chemotherapy

39)Emotional Problems

40)Psychiatric treatment

41)Antidepressant medication

42)Alcohol/Drug Dependency

43)Tobacco (Smoking or chewing), HOW MUCH______

44)Other______

ARE YOU:

45)FEMALE: Taking Birth Control Pills

46)FEMALE: Pregnant

47)Often exhausted or fatigued

48)Subject to frequent headaches

49)MALE: Prostrate Disorders

AUTHORIZATION:I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. If I ever have a change in my Medical and/or Dental history or in any Medications I may be taking I will inform you at my next dental appointment without fail. I acknowledge that providing incorrect and /or inaccurate information has the potential of being hazardous to my health. I authorize the diagnosis of m dental healthby means of radiographs, study models, photographs or other diagnostic aids as deemed appropriate. I authorize the dentist to release any information including the diagnosis and records of treatment for myself and my dependant(s) to third party insurance carriers, payers and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account. I understand that I am financiallyresponsible for any outstanding balance for services provided that are not fully covered by insurance and I may be billed for the remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any).Signature of Patient, Parent or Guardian:

Signature: X ______Date: X______

CONSENT TO RELEASE/REQUEST DENTAL RECORDS

I, ______, do hereby consent and authorize

______to disclose to COLUMBIA FAMILY DENTISTRY information in my record, including current and previous dental records from other practitioners, hospitals and/or clinics which are a part of my record.

My date of birth is ______

This information is strictly for the purpose of identification.

I also consent to the release of dental records by ______in the event any additional information is needed by my insurance company or other providers.

Patient or guardian signature ______

Print ______Relationship to patient: ______

Date: ______

Please send digital x-rays and chart to and or mail to 217 SE 136th Avenue #103, Vancouver, WA 98684

Copies of the following records are specifically requested:

Letters/Reports to/from Specialist

Periodontal Charting

Radiographs