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Mcdowell dentistry


New patients
Welcome to our practice. Our primary purpose is to serve you and your family, to
provide for your dental health needs in a considerate and caring fashion. For your
protection this office has the most modern equipment, the latest techniques, above all, we
follow OSHA guidelines in advanced sterilization technology for both staff and patient
protection.
Consent for Services
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. Financial responsibility on the part of each patient must be
determined before treatment. All emergency dental services, and any dental services
performed without previous financial arrangements, must be paid for in full at time
services are preformed. 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.
(Initials)________

Medical and Dental Authorization
I have read the information on the health questionnaire and it is accurate to the best of my
knowledge. I understand that the dentist to help determine appropriate and helpful dental
treatment will use this information provided. If there are any changes in my medical
status, I will inform the dentist.
(Initials)________
Insurance Authorization
If you have dental insurance, we will gladly process your forms. However, we request
that you pay your estimated portion when services are rendered. Please remember that
our contract for payment is with you and not your insurance carrier.
We are happy
to bill your insurance as a courtesy to you, when you have provided us with your
complete insurance information. We allow 45 days from the date of service for payment
from an insurance company. After this period, we ask you to become responsible for
payment of all unpaid fees.
(Initials)________

Cancelled/Missed Appointments

We reserve the right to charge $40.00 for appointments cancelled or missed without
24hrs-advanced notice.
(Initials)________


Payment Options

Payment is due at the time of treatment. We accept cash, check, and all major credit
cards. We also have two no interest payment plans, Care Credit and All Care, that allows
you to start treatment today and spread payments over time. Applying for Care Credit
and All Care only takes a few minutes and there is no fee to apply. Just as a reminder,
anytime you apply for any type of medical or dental financing, it will not affect your
credit score.
Please indicate below the form of payment you will be using, please check one:
_____ Cash or Check
_____ Major Credit Card
_____ Care Credit or All Care (Subject to credit approval) if credit application is
declined, another form of payment listed above is required.
I HAVE READ THE ABOVE OFFICE POLICIES AND CONDITIONS OF
TREATMENT AND AGREE TO THEIR CONTENT.
___________________________________________________Date_________________
Signature of patient, parent or guardian
PATIENT INFORMATION
Do we have your permission to email you our news let er YES / NO

Responsible Party

Insurance Information

Additional Information

Dental History
Check if you have had problems with any of the fol owing:
Medical History
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Have you had any serious il nesses or operations? Have you had any of the following: please circle List medications you are currently taking and the correlating diagnosis: Authorization and Release
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have change in health. I certify that I, and/or my dependent(s), have assign directly to McDowell Dentistry all insurance
benefits, if any, otherwise payable to me for services rendered. I understand that I am financial y responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named facility may use my health care information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent wil end when the current treatment plan is completed or one year from the date signed Signature of Patient, Parent, Guardian or Personal Representative * Important Medical Alert *
A connection between Fosamax, and other bisphosphonates, with a serious bone
disease called Osteonecrosis of the jaw (ONJ) has been found. Bisphosphonates are commonly used in tablet form to prevent and treat
osteoporosis in postmenopausal women. They are also used in the treatment of Paget’s
disease. Stronger forms given orally or intravenously (IV) are commonly used in the
management of advanced cancers including, but not limited to, lung cancer, breast
cancer, prostate cancer, multiple myeloma, and other masatic cancers. Have you ever taken any of the following bisphosphonates?
Y N Alendronate (Fosamax)
Y N Raloxifene (Evista)
Y N Clodronate (Bonefos, Ostac)
Y N Risedronate (Actonel)
Y N Etidronate (Didronel)
Y N Terparatide (Foreto)
Y N Ibandronate (Boniva)
Y N Tiludronate (Skelid)
Y N Pamidonate (Aredia)
Y N Zoledronate (Zometa)
If yes, when? ____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Prescribing Doctor: ___________________________________ _________________ __________________________________________ __________________________________________ NOTICE OF PRIVACY PRACTICES
McDowell Dentistry
14122 McDowell Road Suite 200
Goodyear, Arizona 85388
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our commitment here at McDowell Dentistry is to serve our patients with
professionalism and caring, being sure at all times to PROTECT the privacy and security of
all Protected Health Information.

During the course of serving your interests, it may be necessary to share
information with other Health Care Providers or Business Associates. The following are
examples of instances where information may be shared:

During treatment, we may find it necessary to consult with a dental laboratory.
For payment purposes, we may use the services of a billing service.
During dental care, we may need to consult with your physician or previous dentist. • For payment purposes, we need to supply information requested from your dental
insurances company.
We here at McDowell Dentistry are committed to obeying all Federal, State, and Local
laws and regulations regarding Privacy Practices. If any other uses or disclosures than
the ones listed above are needed, information will only be released with the written
authorization of the individual in question. The individual, as provided by law, may
revoke this written authorization at any time.

If you have any questions or comments regarding your Protected Health
Information, feel free to contact our Compliance Officer:
Mary Ruiz (623) 536-2040
I have read and understand the above Notice of Privacy Practices.

Signed: ________________________________________ Date: ______/______/______

(Patient or Legal Guardian)
McDowell Dentistry
Cancellation Policy

YOUR DENTAL APPOINTMENT HAS BEEN RESERVED ESPECIALLY FOR
YOU.
THE OFFICE MANAGER WILL CALL THE DAY BEFORE YOUR SCHEDULED
APPOINTMENT TO CONFIRM THE TIME SET FOR YOU.
IF YOU NEED TO CANCEL YOUR APPOINTMENT FOR ANY REASON, KINDLY
GIVE US 24 HOURS NOTICE, OR A $40.00 CANCELLATION FEE WILL BE
CHARGED TO YOUR ACCOUNT.
THANK YOU FOR HELPING US PROVIDE QUALITY DENTAL CARE, BY
RESPECTING THE APPOINTMENT TIME SET FOR YOU.
_____________________________________________

Source: http://www.mcdowelldentistryaz.com/documents/nppacket.pdf

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