Phoenix Smiles Dental Center
Dr. Folake A. Akinbi
9854 Main Street, Fairfax, VA 22031
703-278-8866
Patient Information Today’s Date: ______
Name______Preferred Name______
Home Phone______Work Phone ______Ext. ______Cell Phone______
Home Address______
City______State ______ZIP ______
Gender: ______Family Status: ______Date of Birth: ______
***Email______ SSN ______- ______- ______
Health Information Date of last Dental Visit : ______Reason for todays visit:______
Bleeding Disorder YES / NO High Blood Pressure YES / NO
Diabetes YES / NO Kidney Problems YES / NO
Dialysis Treatment YES / NO Pain in Jaw / TMJ YES / NO
Epilepsy / Seizures YES / NO Rheumatic Fever YES / NO
Heart Disease YES / NO Sickle Cell Anemia YES / NO
Heart Murmur YES / NO Stroke YES / NO
Heart Valve Replacement YES / NO Thyroid Condition YES / NO
Hepatitis YES / NO Tuberculosis YES / NO
Knee / Hip Replacement YES / NO HIV/ HIV positive YES / NO
Have you ever had any complications following dental treatment? YES / NO
If yes please explain: ______.
Do you have any allergies? YES / NO Are you allergic to Penicillin? YES / NO Are you Allergic to Latex/Rubber? YES / NO
Allergic to any Medications? YES / NO (List All) ______.
Allergic to Dental Anesthetics (Numbing) YES / NO
Have you been admitted to a hospital or needed emergency care during the past two years? YES / NO If yes, please
Explain: ______.
Are you currently under the care of a physician? YES / NO If yes, please explain: ______
______.
Are you currently taking any medications? YES / NO If yes, please list all medications: ______
______.
Name of Physician: ______Phone no.: ______
Do you have any health problems that need further clarification? YES / NO If yes, please explain: ______
______.
Please provide the name and phone number of the person you wish we may contact in the event of an emergency:
Name: ______Relationship: ______Phone no.: ______
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor and the next appointment without fail.
______ Date: ______
Patient signature/ parent or guardian
Spouse or Responsible party Information
The following is for patient’s Spouse ______, Parent ______the person responsible for payment.
Name: ______Date of Birth: ______Social Security no. ______
Home phone no. : ______Work no. ______Cell no. :______
Address: ______City/ State: ______Zip code: ______
Employer: ______Occupation: ______
Primary Insurance
Subscriber’s name: ______Date of Birth______Employer: ______
Name of Insurance: ______Group no. # ______Insurance ID#______
Insurance ph. No. : ______Address: ______City/State: ______
Relationship to patient ÿ Self ÿ Spouse ÿChild ÿOther ______
Secondary Insurance
Subscriber’s name: ______Date of Birth______Employer: ______
Name of Insurance: ______Group no. # ______Insurance ID#______
Insurance ph. No. : ______Address: ______City/State: ______
Relationship to patient ÿ Self ÿ Spouse ÿChild ÿOther ______
Consent for Services
Informed Consent
Problems arising from dental treatment are extremely rare but may include pain or infection. Not treating dental disease may have the same result. If a tooth cavity is very deep and the nerve and blood supply are affected, or if bone loss or swelling are present, the removal of the nerve or the tooth with local anesthesia, may be necessary. Please feel free to discuss any concerns you have with Dr.Akinbi and Staff. I authorize the Dentist to perform on my child or myself a dental examination and treatment such as cleaning, treatment of gum disease, fluoride and sealant applications, fillings with local anesthesia and other treatments as deemed necessary by the dentist.
Date: ______Signature: ______
(Patient/Parent/Guardian)
Notice of Deemed Consent for HIV, HBV and HCV Testing
If one of our health care professionals, workers or employees should be directly exposed to your blood or body fluids in a way that may transmit disease, your blood will be tested for infection with Human Immunodeficiency Virus (HIV, the AIDS Virus) and for the presence of the Hepatitis B and Hepatitis C Viruses. A physician or other health care provider will tell you and that person the result of the test and provide counseling, if necessary. If you should be directly exposed to blood or body fluids of one of our health care professionals, workers or employees in a way that may transmit disease, that person’s blood will be tested for infection with Human Immunodeficiency Virus (HIV, the AIDS Virus) and for the presence of the Hepatitis B and Hepatitis C Viruses. A physician or other health care provider will tell you and that person the result of the test and provide counseling, if necessary.
Date: ______Signature: ______
______Date: ______Relationship to Patient: ______
Signature of Patient, parent or guardian
______Date: ______Relationship to Patient: ______
Signature of Guarantor of payment / responsible party
New Patient Form 2015/ PSDC forms
Phoenix Smiles Dental Center
Financial Agreement
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and 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 full (cash/check/credit card) at the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services to include any services downgraded by your insurance and you will be financially responsible for the difference in cost. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. Patient will be responsible for unpaid balances and services not paid by the insurance after sixty days.
A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
I understand that I must provide a 48 hour notice when rescheduling or canceling an appointment to avoid being charge a broken appointment fee. The doctor will set aside time, staff and instruments for my scheduled visit and is prepared when I arrive, therefore I will offer the same courtesy when rescheduling my appointments and provide a forty eight hours-notice.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or her assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. 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 suit were instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form and my treatment.
I have read the above conditions of treatment and payment and agree to their content.
______Date: ______
Patient /Guardian Signature
PSDC forms/patient update 2015