HEATH HISTORY & REGISTRATION
PATIENT INFORMATION
INSURANCE INFORMATION
YES NO (select one)
Cash Check Credit Card CareCredit

My signature authorizes release of my medical information and x-rays; and authorizes payment directly to Max S. Breazeal, D.D.S. upon complestion of treatment.

OFFICE POLICY
INSURANCE

I UNDERSTAND THAT DR. BREAZEAL IS AN OUT OF NETWORK PROVIDER AND THAT I AM RESPONSIBLE FOR MY INSURANCE DEDUCTIBLE AND CO-PAYS, SET OUT BY MY INSURANCE COMPANY, ON THE DAY SERVICES ARE RENDERED. I also understand that my dental insurance is a contract between me and the insurance company, not between the insurance compkany and Dr. Breazeal. I UNDERSTAND THAT AS A COURTESY TO ME, DR. BREAZEAL'S OFFICE WILL FILE MY INSURANCE, HOWEVER I AM STILL RESPONSIBLE FOR ALL DENTAL CHARGES. If the insurance complany has not paid their portion within 30 days of being properly billed, as mandated by the insurance Commissioner of the State of Tennessee, I understand that the balanace will become due and payable from me.

DELINQUENT ACCOUNTS

I understand that payment is due at the time services are rendered unless payment arrangements have been made adn approved in advance. All unpaid balances will be subject to a finance charge after 90 days of 1.5% per month, which is an annual percentage rate of 14%. In the event we are forced to submit a delinquent account to a collection agency, I agree to reimnurse any fees of any collection agency, which will be 33% of the debt, and all costs, and expenses, including reasonably attorney's fees we incur in such collection effots, which will be added at the time the account is sent for collection.

FAILED APPOINTMENT CHARGE

I understand that as a courtesy to me, I will either be called, emailed or texted the day before the appointment to confirm. We are reserving that time exclusivly for you, if for any reason you can no longer make your appointment please call within 24 hours to cancel or reschedule. Otherwise, you will be charged for a failed appointment fee. If I fail my appointment without giving 24 hrs notice a $25 FAILED APPOINTMENT CHARGE will be added to my account. If the appointment was for two hrs, there will be a charge for $50 added to my account.

RETURNED CHECKS

All returned checks are subject to a $50 service fee. Any returned check must be resolved before any future appointments can be arranged.

I understand that responsibility for payment for dental services provided for my dependent or myself is MINE, due and payable at the time services are rendered.

It is important that I know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

MEDICAL HISTORY
YES   NO
WOMEN
PREGNANT/Trying to get pregnant?    Nursing
Taking oral contraceptives?
Are you allergic to any of the following?
Asprin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Nitrous Oxide Sulfa Drugs
Other   
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortizone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepititis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatment
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swlling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
DENTAL HISTORY
 
YES   NO
Would you like to know more about
How do you feel about your teeth?
LIST ALL MEDICATIONS TAKEN DAILY
(Prescribed and Over the Counter)

YES NO