TODAYS DATE
PATIENT INFORMATION:
LAST NAME TITLE FIRST NAME
MI PREFERRED NAME SEX: M F
SSN DATE OF BIRTH: / / MARITAL: S/M/D/W
HOME ADDRESS
CITY STATE ZIP
HOME PHONE WORK PHONE CELL PHONE
RESPONSIBLE PARTY:
Parent/Guardian if patient is a minor Relationship to Patient
HOME PHONE WORK PHONE CELL PHONE
EMERGENCY CONTACT NAME: Relationship to Patient:
HOME PHONE WORK PHONE CELL PHONE
WHO MAY WE THANK FOR REFERRING YOU:
Friend Referral Care to Share Card Mail Insurance Co. Internet ZocDoc Other
EMPLOYER: Occupation
ADDRESS OF EMPLOYER
CITY STATE ZIP
INSURANCE COVERAGE:
INSURED’S NAME
INSURED’S SSN INSURED’S DATE OF BIRTH
INSURED’S EMPLOYER
INSURANCE CO. NAME GROUP #
INSURANCE COMPANY PHONE #
DENTAL HISTORY
Last Dental Visit: When did you last have x-rays?Are you nervous about dental treatment?
Is there anything about your mouth that concerns you now?What type of toothbrush do you use? Soft Medium Hard
Do you use dental floss? Toothpicks? How often?
Do your gums ever bleed?
Are any of your teeth mobile (loose)?
Do you have any swelling, sores or blisters in your mouth?
Have you ever been instructed in how to prevent tooth decay?
Have you ever been told you have gum disease?
Do you smoke? Chew tobacco?
Do you feel you have unpleasant breath at times?
How would you describe your dental health?
SMILE EVALUATION
Are your teeth all in alignment (straight)?Do you have missing teeth? Are any chipped?
Is your bite comfortable for chewing, biting?
Do you have frequent headaches?
Do you have any old fillings or dental work that you don’t like?
If you had a magic wand and could create your perfect smile, what would it look like?
Are you aware of the new techniques in dentistry?
AnyAdditional Comments You Need To Share
Practice Policies
Financial Policy
oOur office accepts cash, checks, MC/VISA, Discover and American Express
oConvenient Monthly Payment Options from Care Credit Healthcare Credit Card are offered
toallow you to pay over time. No interest for 6 or 12 month loans.
oI understand that all payments are due at the time that services are rendered. If payment cannot be made in
full, you must inform our office prior to your appointment time to see if financial agreements can be made.
o If you carry dental insurance, we will kindly file it for you; however, any co-payments are due the day of
service.
oYou are responsible for keeping our office updated with your current dental insurance plan. Any changes in
coverage need to be given to the front staff no later than 24 hours prior to your appointment.
o When Dr. Stryker diagnoses any necessary treatment, our office can only estimate the amount your insurance
will pay to the best of our ability, based on the information given to us from your insurance carrier. This is not
a guarantee of payment.
oFor all patients that do not pay in full at the time of service, we kindly request that you leave a credit card
number on file as a guarantee for any remaining balance not paid by your dental plan.
oAnyone age 17 and under must be accompanied by an adult.
Appointment Policy
oYour appointment is reserved exclusively for you. If you need to reschedule your appointment, please
verbally notify our office at least 48 business hours in advance. This will allow our office ample time to offer
your appointment to another patient in your absence.
oWe do not accept changes to the schedule on our voicemail system. Kindly contact our office directly for all
schedule changes.
oAs a courtesy to you, all appointments will receive a 2-week early reminder from our office. At that time, we
ask that you reply to confirm the appointment, and update our office of any changes in your contact
information, and/or insurance information.
oA fee of $25 is charged for patients who miss their first appointment without 24-hour notice.
oIf a patient has three (3) last-minute cancellations or missed appointments; we reserve the right to either:
· accept them only on a “same day basis” as a walk-in during an open appointment time, or,
· terminate the patient/doctor relationship.
CONSENT:I have read the above Financial and Appointment Policies and understand and accept its application to me and any minors for which I am responsible. To the best of my knowledge, all the questions on this form have been accurately answered.
I give the dentist permission to use my reviews, photographs and/or videos for educational and promotional purposes.
I authorize the Dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.
I authorize the release of any information concerning my (or my child’s) health care, medical history, advice and
treatment to another dentist of if applicable, an insurance company
______
Patient/Guardian Name (Printed)
______
Patient/Guardian Signature Date
Michael M. Stryker, D.D.S.
Family & Cosmetic Dentistry
15600 San Pedro Avenue, Suite 300
San Antonio, Texas 78232
210-496-1118
Dear Patient:
In an effort to provide you with flexible payment arrangements, we have expanded our payment policy.
PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT
We now offer the following payment options:
Payment by cash
Payment by check
Payment by credit or debit card
(Visa, MasterCard, Discover, American Express, Care Credit)
Automatic monthly billing to your Visa or MasterCard
Guarantee any amount not covered by insurance with Visa or MasterCard
Please make your choice, sign below and return to office manager before treatment.
Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa and MasterCard to automatically cover amounts not paid by your insurance. You may also choose a comfortable amount to be automatically billed to your Visa or MasterCard on a monthly basis.
If none of the above apply, please see the office manager. Thank you.
Print Your Name
Signature
Date