Diamond State Dentistry - Patient Forms

Form: Practices and Responsibilities

Patient Information

FIRST Name

LAST Name

Welcome to Diamond State Dentistry

We would like to take this opportunity to welcome you and at the same time familiarize you with some of the treatment possibilities you may encounter on your first and/or subsequent hygiene appointments. After reading, please check the box and sign below.

Children (17 yrs and younger)

Each 6 month visit includes a prophylaxis cleaning), a fluoride treatment and an exam. Two (2) or four (4) digital images are taken on the first visit and then yearly thereafter. A Panoramic X-ray may be taken every 5 years as determined necessary.

*Minor children will not be treated without parent or legal guardian physically present.*

Adults (with good oral health)

Each 6 month visit includes a prophylaxis (cleaning) and an exam. Two (2) or four (4) digital images are taken on the first visit and then yearly thereafter. A fluoride treatment is recommended and will be provided per request at a small additional fee.

Adults (with irregular checkup history)

Your care may be altered from the above as determined by the hygienist/doctor. A full series of digital images may be necessary and all that time allows during your initial visit. If further treatment is rendered at this visit, it may be part of a treatment process. Your treatment process may include more detailed cleaning visits or referrals to a specialist in the beginning followed by care and maintenance at our office. The treatment specific for you and any added expenditures will be explained to you by the hygienist.

All Adults

We normally recommend a full mouth series of digital images when you begin with us and every (5) five years or so thereafter. Additionally we recommend bitewing xrays yearly and may also recommend periodic xrays of specific teeth or implants. This allows for proper monitoring of the entire mouth.

I have read the above and understand that I have the right to question or refuse any treatment recommended. It is my duty to inform the doctor/hygienist of my wishes before treatment ensues.

Financial Responsibility Policy

It is the responsibility of the patient to provide Diamond State Dentistry with current and complete insurance information. If you have dental coverage through more than one carrier, please be sure to inform the staff as such so that claims and charges can be submitted and calculated correctly.
Please be sure to show the administrative staff your dental insurance card at every visit.
As a courtesy, we will submit claims for payment so your dental insurance company can properly apply your benefits. It is the responsibility of the patient, however, to know and understand the benefits and limitations of his or her particular insurance policy.
If a claim is denied, the administrative staff will research the matter and resubmit to the insurance company or bill you the appropriate balance. If the claim is denied a second time, the appropriate balance will immediately become the patient’s responsibility and should be paid to Diamond State Dentistry directly. You may then contact your insurance company for reimbursement if it is due to you.
Regardless of insurance coverage, payment for services rendered is ultimately the responsibility of the patient or the responsible party for that patient. Diamond State Dentistry cannot guarantee payment of claims from any insurance company.
The patient is responsible for payment of any applicable or estimated co pays or deductibles on the day of service. Upon receipt of insurance payment, the patient will be billed for any applicable balance that was not paid by his or her carrier. In the event that the insurance carrier pays more than was estimated, Diamond State Dentistry will either refund the patient the appropriate amount or credit the patient’s account accordingly.
Patients that do not have dental insurance will be required to pay for services at the time that services are rendered unless a signed financial agreement has been approved.

Insurance benefits are estimates only. I understand that I am responsible for any co-payments, deductibles, and procedures that my insurance company does not cover. I authorize the dentist to release my information, including diagnostic information and treatment records for me and any of my dependents during the period of treatment to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist, insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered and any collection fees accumulated on my behalf or that of my dependents.

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I consent to use Electronic Records and Signatures (Read Electronic Record and Signature Disclosure)

Relationship to patient

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