PHILLIP S. ZEIP, D.D.S.
3315 Mission Drive Ste. A
Santa Cruz, CA 95065
Phone: (831) 475-3853 www.phillipzeipdds.com
*Patient Registration Form----Please Print
Welcome to Dr. Phillip S. Zeip’s dental office. Dr. Zeip and staff are highly complimented that you have selected this office to provide dental care for you and your family.
Whom may we thank for referring you?______
Patient’s Name:______SS#:______
Street Address:______
City:______State:______Zip code:______
Home Phone:______Cell Phone:______Work Phone:______
Patient’s Email:______
Birthdate:______M F Age:______
Patient Employed By:______Occupation:______
Spouse’s Name:______Spouse’s Phone:______
Previous Dentist:______Phone Number:______
Name of Primary Insurance Co:______
Policy Holder Name:______Policy Holder DOB:______
Policy Holder SS#:______Relationship:______
Name of Secondary Ins. Co:______
Policy Holder Name:______Policy Holder DOB:______
Policy Holder SS:______Relationship:______
*If Patient is a Minor:
Father’s Name:______Mother’s Name:______
Address:______Address:______
Phone:______Phone:______
DOB:______SS#______DOB:______SS#______
In case of emergency, who should be notified?______
KINDLY PROVIDE 24 HOURS CANCELLATION NOTICE TO AVOID A
CANCELLATION/NO SHOW FEE.
PHILLIP S. ZEIP, D.D.S.
3315 Mission Drive Ste. A
Santa Cruz, CA 95065
Phone: (831) 475-3853 www.phillipzeipdds.com
Financial and Appointment Consent Form
We welcome you and your family to our office. We ask that you review and complete our office and financial policy consent form to provide you with most beneficial and comprehensive services and care. We will gladly discuss your treatment plan, financial options and any other questions you may have.
Dental Insurance
If you have dental insurance we will file the claims for you as a complimentary service. We do ask that the correct insurance information be provided at the time of you appointment in order for us to timely file the claim and collect insurance payments.
Our office will provide you with an approximation of your out of pocket expense for any treatment planned by the doctor. However, please understand that these are only estimates and are not a guarantee of insurance payment. Please note that any difference in payment from insurance company is your responsibility.
Payment / Copays / Deductibles
Payment for copays and/or deductibles (estimated patient portion) is due at the time the services are provided.
We offer the following payment options:
1. Payment by cash or Check.
2. Credit card (Visa, MasterCard and Care Credit).
Cancellations and Broken Appointments
We respectfully request a 24 hour cancellation notice. Cancellations must be made during business hours.
Your scheduled time has been saved for you and the doctor and/or hygienist.
If less than 24 hours’ notice is given for an appointment a non-refundable $50 cancellation fee will apply.
We do our very best to contact you 1-2 days prior to your scheduled appointment.
Please leave your cell phone and e-mail so that we may better reach you.
Cellular______
E-mail Address______
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction.
Print Name______Date______
Signature______
PHILLIP S. ZEIP, D.D.S.
3315 Mission Drive Ste. A
Santa Cruz, CA 95065
Phone: (831) 475-3853 www.phillipzeipdds.com
Patient Name______
Dental Treatment Consent Form
1. Health information: I agree to disclose all previous illnesses and medical history. Undisclosed medical information, current medications, allergies or illness are risk factors.
2. Drugs, latex and medicines: I understand that antibiotics and other medicines can cause allergic reactions and even life-threatening anaphylaxis. Also, some antibiotics interfere with birth-control pills. Latex allergy can cause rashes and itching. Epinephrine increases the heartbeat and, depending on my health, may be dangerous to me.
3. Needle stick: If someone is inadvertently stuck with a needle used on me, I consent to have blood drawn for analysis.
4. Filings, crowns and un-anticipated root canals: Some teeth may need a root canal even after a simple filling. Fillings and crowns do take away tooth structure and a percentage of these teeth end up needing a root canal after the filling or crown is done.
5. Root canals can fail: Root canals can fail and may require additional treatment or the tooth may not be salvageable and need extraction.
6. Porcelain crown, veneers, bonding and cosmetic fillings: Porcelain crowns, veneers, cosmetic bonding and composite fillings are aesthetically pleasing; however, I understand that if they chip or break after in use successfully, I am responsible for repairs or remakes. Once a crown, veneer, bonding or filling is placed, I understand the color cannot be changed.
7. Extraction and surgery: I understand that all dental extractions or surgeries carry risks for example, a dry-socket following an extraction. Some risks are life threatening such as post-surgical infection or anaphylaxis.
8. Fee for additional or specialty care: I understand that I may need treatment beyond what was originally planned ( a crowned tooth becomes painful and will need a root canal), or I may be referred to a specialist for additional care (root canal was not successful). I agree to be financially responsible for the additional or specialty care.
9. Limitations of insurance coverage: There are charges beyond what insurance will pay, e.g. nitrous oxide, oral sedation, bleaching or cosmetic work. Also, as a service to patients, this office will file insurance claims on their behalf. I understand that what may be quoted as my portion (co-payment) is only an estimate. I agree to be financially responsible for what insurance does not cover.
10. 24 hour notice for cancellation: I agree to give 24-hour notice for cancellations or pay the broken appointment fee. I understand that leaving a message after the office is closed the day (or weekend) before is NOT sufficient notice.
11. Hygiene appointments: If I am more than 15 minutes late for my cleaning appointment, I will either take my remaining time or reschedule and pay a broken appointment fee.
12. I acknowledge the receipt of notice of privacy practices and my personal information will not be shared with anyone.
13. I acknowledge I have received a copy of the dental materials fact sheet dated 5-1-04 as required by law from Phillip Zeip DDS.
I do not expect guarantees in dental care. I have read the above and consent to the treatment.
______
Signature of patient or guardian Date Witness