online forms

Please take the time to print and fill out the forms below. You may bring these forms in before your first appointment.

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Office Policies and Financial Responsibilities


PAYMENTS are due at the time of treatment. For your convenience, we offer the following payment arrangements: Cash, Personal Checks, Money Orders, Visa, MasterCard, American Express, Discover, Care Credit and Citi Health Card. A RETURNED CHECK FEE OF $35.00 will be charged to any account for any check returned for insufficient funds

INSURANCE claims are filed for you as a courtesy. Dental insurance is a contract between you and your insurance carrier. Our goal is to help you maximize insurance benefits available, so we can assist you in making excellent dentistry affordable. We base our ESTIMATES on the information we receive from your insurance plan. You will responsible for the ESTIMATED patient part plus a deductible, if applicable , at the time of service. If there are any changes in your plan or coverage, it is your responsibility to provide the information PRIOR to being seen. If for any reason any claim is denied / and or unpaid the patient/guarantor is responsible for those charges.

CANCELLATIONS are a pain for everyone. Please understand we have reserved appointment time just for you. We schedule hygiene appointments up to 6 months in advance. We highly recommend this to assure you get an appointment time that will meet your scheduling needs. We realize on occasion, that things may arise to keep you away. We ask that you notify us as soon as possible, but no later than 24hours in advance of the appointment to avoid a $25 charge to your account.

DELINQUENT ACCOUNTS will be subject to collection activities and all information will be sent to all major CREDIT AGENCIES. You will be responsible for all fees and charges applicable by law. Any account overdue by 30 days will receive a monthly billing fee, UNLESS OTHER PAYMENT ARRANGEMENTS HAVE BEEN MADE.

I certify that I am the patient or authorized general agent of the patient. I have read and fully understand my financial responsibilities under this policy.
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Samuel J. Holcroft, D.M.D., P.A


PATIENT

Sex

Marital Status

Dental Insurance

See below for necessary Information

SPOUSE/ PARENT/ RESPONSIBLE PARTY: If Applicable

DENTAL INSURANCE

MEDICAL HISTORY

Are you taking any medication?

If, yes, please continue. List all medications, purose and dosage below

Are you ALLERGIC to or have you had a reaction to any of the following?

Local Anesthesia (e.g. Novacain)

Codeine/ Sedatives/ Sleeping Pills/ Narcotic

Penicilin/ Other Antibiotics

Aspirin

Sulfa Drugs

WOMEN ONLY:

Are you pregnant?

Nursing

Are you taking Birth Control Pills? (Antibiotics make birth control pills ineffective)

Do you have or have you had any of the following?

Heart Disease/ Attack/ Surgery

Tumors/ Growths

Angina

Cancer

High Blood Pressure

Radiation/ Chemotherapy

Artificial Heart Valves

Arthritis

Heart Pacemaker

Glaucoma

Artificial Joints

HIV / AIDS

Pre-medicate for Dental Treatment?

Hepatitis A, B, C

Stroke

Liver Disease

Kidney Problems

Alcoholism

COPD

Drug Addiction

Tuberculosis (TB)

Hemophilia

Asthma

Cold Sores

Diabetes

Epilepsy or seizures

Sickle Cell Disease

Thyroid Disease

Is there any disease, condition or problem you have that we should be aware of? Is there any activity your doctor said you could not or should not do? Explain

Reason for this visit?

Last Dental APPT?

Does dental treatment make you nervous?

Treated for Periodontal Disease (Gum Disease, Pyorrhea, Trench Mouth)?

Please select if Applicable

I have completed this for to the best of my ability. I am the patient or the patient's authorized agent/guardian and am qualified to answer these questions.

Printed Name

Date

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