Welcome

Our dental team is happy to welcome you to our practice. We are pleased you have chosen us to help you care for your dental health. We are committed to providing you with the highest quality of dental care. The first visit to our office will consist of a complete oral examination. We will be taking only the necessary x-rays and performing any other tests needed to make a complete diagnosis of the conditions of your mouth, teeth, gums, jaw, joints, and muscles. We will then be able to determine what treatment is necessary for your dental healthcare. We understand your time is valuable. We will always do our utmost to respect your time, and do our best to see you on time for your scheduled appointment. However, we do ask that you understand this is a medical facility and emergencies do arise. In order to keep the schedule running smoothly and efficiently we request at least 48 hours notice if you need to reschedule your appointment time. There is a $75.00 dollar “no show”, or a “short cancel”, fee that will apply to every appointment with less than a 24 hour notice. Please complete the attached health record and financial policy. If you have any questions, please do not hesitate to ask. Thank you, Dr. Swain & Staff

PATIENT REGISTRATION

Date: ________________

Patient Information:

First Name: __________________________ Last: ______________________________ MI: _____ Preferred Name: _________________________

Address: ______________________________________________________________ City: ________________ St: _____ Zip:__________________

Cell Phone: _________________________ Work Phone: __________________________ Ext:________ Hm. Phone: _________________________

Gender: Female Male Marital status: Married Single Divorced Widowed

Birth Date: ____________________ Age: ____________ SS#: ___________________________ Drivers Lic: ________________________________

Email: ___________________________________________________

Who should we contact in case of emergency: ___________________________ Relationship: ______________________Phone: _______________

Responsible Party (if different than patient):

First Name: __________________________ Last: ______________________________ MI: _____ Preferred Name: _________________________

Birth Date: ____________________ Age: ____________ SS#: ___________________________ Drivers Lic: ________________________________

Address: ______________________________________________________________ City: ________________ St: _____ Zip:__________________

Cell Phone: _________________________ Work Phone: __________________________ Ext:________ Hm. Phone: _________________________

Email: ___________________________________________________

Fill Out If Insurance Will Be Billed

Primary Insurance Information: Secondary Insurance Information:

Subscriber Name: ___________________________________ Subscriber Name: ________________________________________

Date of Birth: _______________________________________ Date of Birth: ____________________________________________

Relationship to Subscriber: Self Spouse Child Other Relationship to Subscriber: Self Spouse Child Other

Subscriber SS#: _____________________________________ Subscriber SS#: __________________________________________

Employer: _________________________________________ Employer: ______________________________________________

Insurance Company: _________________________________ Insurance Company: ______________________________________

Member ID#: _______________________________________ Member ID#: ____________________________________________

Group #: __________________________________________ Group #: ________________________________________________

WHOM MAY WE THANK FOR REFERRING YOU/HOW DID YOU HEAR ABOUT US? ___________________________________________

MEDICAL AND DENTAL HISTORY INFORMATION

Date: _____________

Dental History: Last Dental Visit: __________________________ Reason for today’s visit? ___________________________________________________________ How often do you brush your teeth? ____________________________ How often do you floss? ______________________________________ Do your gums bleed when you brush? Yes No Do you have problems with bad breath? Yes No Have you ever had an oral cancer screening? Yes No Do you snore? Yes No Have you or family member been treated for periodontal disease? Have you ever had a popping or clicking near your ear when you chew? Yes No Yes No Have you ever had complications from an extraction? Yes No Are you prone to frequent headaches? Yes No Do you have sores, blisters or swelling on your gums, lips or cheeks? Have you ever had an allergic reaction to a crown or a metal filling? Yes No Yes No Do you grind or clench your teeth? Yes No Are your teeth sensitive to hot, cold or pressure? Yes No Have you ever used an electric toothbrush? Yes No Have you ever had orthodontic treatment? Yes No

On a scale from 1 to 10, with 10 being the highest, how important is your dental health to you? 1 2 3 4 5 6 7 8 9 10 If you could change something about your smile what would it be: _________________________________________________________________

Medical History: AIDS/HIV Positive Yes No Alzheimer’s disease Yes No Anaphylaxis Yes No Anemia Yes No Angina Yes No Arthritis/Gout Yes No Artificial Heart Valve Yes No Artificial Joint Yes No Asthma Yes No Blood Disease Yes No Blood Transfusion Yes No Breathing Problem Yes No Bruise Easily Yes No Cancer Yes No Chemotherapy Yes No Chest Pains Yes No Cold Sores Yes No Congenital Heart Disorder

Yes No Convulsions Yes No

Cortisone Medicine Yes No Diabetes Yes No Drug Addiction Yes No Easily Winded Yes No Emphysema Yes No Epilepsy/Seizures Yes No Excessive Bleeding Yes No Excessive Thirst Yes No Fainting Spells/Dizziness Yes No Frequent Cough Yes No Frequent Diarrhea Yes No Frequent Headaches Yes No Genital Herpes Yes No Glaucoma Yes No Hay Fever Yes No Heart Attack/Failure Yes No Heart Murmur Yes No Heart Pacemaker Yes No Heart Trouble/Disease Yes No

Hemophilia Yes No Hepatitis A Yes No Hepatitis B or C Yes No High Blood Pressure Yes No High Cholesterol Yes No Hives or Rash Yes No Hypoglycemia Yes No Irregular Heartbeat Yes No Kidney Problems Yes No Leukemia Yes No Liver Disease Yes No Low Blood Pressure Yes No Lung Disease Yes No Mitral Valve Prolapse Yes No Osteoporosis Yes No Pain in Jaw Joint Yes No Parathyroid Disease Yes No Psychiatric Care Yes No Radiation Treatment Yes No Recent Weight Loss Yes No

Renal Dialysis Yes No Rheumatic Fever Yes No Rheumatism Yes No Scarlet Fever Yes No Shingles Yes No Sickle Cell Disease Yes No Sinus Trouble Yes No Spina Bifida Yes No Stomach/Intestinal Disease Yes No Stroke Yes No Swelling of Limbs Yes No Thyroid Disease Yes No Tonsillitis Yes No Tuberculosis Yes No Tumors of Growths Yes No Ulcers Yes No Venereal Disease Yes No Yellow Jaundice Yes No

Are you under a physician’s care now? Yes No Physician’s Name & Number: _________________________________________________

Have you been hospitalized or had major operation? Yes No Have you had any serious illness not listed above?_____________________________

Are you Allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa Drugs Bananas Other: _____________________________________________ Are you taking or have you ever taken bisphosphonates? (Fosamax, Boniva, Actonel for osteoporosis, chemotherapy, etc) Yes No

Do you use tobacco? Yes No Do you use controlled substances? Yes No

Please list all medications you are taking: _________________________________ ___________________________________________________________________ ___________________________________________________________________ _______________________________________________________________________________________________________________________________

Patient (Parent/Guardian): __________________________________________ Date: ___________________________________________ Doctor: __________________________________________________________ Date: ___________________________________________

Women Only: Pregnant/Trying to get Pregnant?

Nursing Taking Oral Contraceptives?

Consent Form and Financial Policy

Mission Statement: Our goal is to build a long term relationship between our staff and our patients so that we can provide quality, consumer friendly, dental services the whole family can value and afford in a happy and healthy environment. Scheduled Appointments: I agree to give a minimum of 24 hr notice to reschedule or cancel my exclusively reserved appointment time. My dental appointment represents a shared responsibility for both dentist and patient. In order to have quality dental care at affordable costs, these appointments must be kept. I understand and agree that if proper notice is not given, I will be charged a fee up to the amount of the scheduled procedure with a minimum fee of $75.00. Texting: By initialing here _________ I give my permission for Gilbert Smiles to use my mobile phone number to text appointment notifications and confirmation of appointments. HIPAA Agreement: A notice/copy of Gilbert Smiles HIPAA Privacy Practices has been made available to me explaining how Gilbert Smiles protects my confidential health information and what my rights are a patient. I give permission to Gilbert Smiles to contact me in writing, by E-mail or by telephone at home, work, or cellular phone to discuss any matters related to my account, appointments or any other matter relating to my treatment and care. Financial Policy: We are committed to providing you with the best possible care. In order to achieve this goal we need your assistance and your understanding of our payment policy. Payment for services is due on or before the day services are performed unless other arrangements have been made and approved in advance. We accept Cash, Check, Care credit, American Express, Master card, Visa and Discover. Financial arrangements will only be made with a credit card on file and on case by case bases. Funds will be drafted each month on the agreed date. In addition, I understand and agree to pay any unpaid balance within thirty days of date of invoice. I will be charged a late fee of $25.00 per month for any unpaid balance on my account. I will be responsible for any collection, attorney and/or court fees associated with my account. This office is not a party in any divorce decree. Adult patients are responsible for their bill at the time of service. The responsibility for a minor’s bill always rests with the accompanying adult. A parent or adult is required to remain in the office at all times while treatment is being rendered for a minor. If Insurance Is Involved: We will file claims on your behalf in most cases. Please understand that this is a medical facility and Dr. Swain cares about your health. It is Dr. Swain’s responsibility to advise you of the status of your dental health and advise you of treatment needed based on your specific needs NOT based on your insurance coverage. We do not take responsibility for your insurance plan, their fees, allowances, limitations and specifications. There are hundreds of insurance plans and it is impossible for us to know them all. Therefore it is the patient's responsibility to know and understand their individual plan. If you have specific questions about your plan you should contact your insurance directly. It is your responsibility to provide us with your correct insurance information, including the insurance company name, address, phone number, group name and number and any other pertinent information, as well as cooperate with your insurance company to provide information to them if requested. We are unable to bill your insurance or provide you with an estimate if the information we have is not up to date. Please Be Advised: We bill your insurance as a courtesy to you. However we do not take responsibility for your insurance plan, their fees, allowances, limitations and specifications. There are hundreds of insurance plans and it is impossible for us to know them all. Therefore it is the patient's responsibility to know and understand their individual plan. If you have specific questions about your plan you should contact your insurance directly. WE WILL DO OUR BEST TO ESTIMATE WHAT INSURANCE WILL PAY AND WHAT THE PATIENT PORTION WILL BE FOR YOUR TREATMENT. THE ESTIMATED PATIENT PORTION WILL BE DUE AT THE TIME OF TREATMENT. ANY AMOUNT NOT PAID BY YOUR INSURANCE, REGARDLESS OF THE REASON, IS YOUR RESPONSIBILITY. WE THEREFORE REQUIRE A CREDIT CARD TO BE ON FILE FOR ANY BALANCE NOT PAID BY YOUR INSURANCE COMPANY.

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Circle preferred method of payment: VISA/MC/AMEX/DISCOVER/CARECREDIT CARD#____________________________ EXP DATE ___________________ SECURITY CODE___________ CARD HOLDER SIGNATURE______________________________________ I authorize the aforementioned form of payment for the following family members: ____________________________________________________________________________________________________ Signature: ___________________________________________ Date: _____________________ If you have secondary insurance we will bill it for you however we are not able to give estimates for secondary Insurance. Terms & Conditions: I, the undersigned, agree to all financial policies as listed above. All emergency dental services, or any dental services performed without prior financial arrangements, must be paid for by one of the above mentioned methods of payment the day services are performed. I understand that all dental services furnished to me are charged directly to me and that I am personally responsible for payment of all dental services. If I carry insurance, I understand this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental office cannot render services on the assumption that charges will be paid by an insurance company. I understand if any balance becomes delinquent over thirty (30) days, it is agreed that Gilbert Smiles will have the authority to debit my charge account listed above or any payment form on file including CareCredit. We will impose a late payment charge of 1.5% per month (or maximum allowed by law). It is further agreed that I will be responsible for the attorney’s fee and any other related costs for collection in the event that this account requires collections. Assignment of Benefits: I herby authorize my insurance company to pay directly to my dentist, benefits accruing to me under my policy. I herby authorize Gilbert Smiles staff to make insurance inquires on my behalf to insure proper handling and payment of all claims. By signing below, I acknowledge being provided with a copy of “Dental Insurance Basics” (pages 1-3) that is designed to better explain how my dental insurance works and answer any questions I may have. I HAVE READ THE ABOVE CONDITIONS OF TREATMENT AND PAYMENT AND AGREE TO THEIR CONTENT. Patient Name: ________________________________ Patient/Parent Signature: ______________________________________ Date: _________________________________ Page 2 of 2

Oral Screening Consent Form Complete each time the examination is performed and place in the patients chart.

Our practice continually looks for advances to ensure that we are providing the optimum level of oral health to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both incidence and mortality rate of oral cancer continue to increase. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such lifestyle risk factors. Oral cancer risk patient profile is as follows: Oral cancer risk by patient profile is listed below: Increased Risk: Patients age 18-39 and sexually active patients (HPV 16/18) High Risk: Patients age 40 and older; tobacco users younger than age 40 Highest Risk: Patients age 40 and older and lifestyle risk factors (tobacco use); patients with a history of oral cancer We have incorporated ViziLite Plus into our oral screening standard of care. We find that using ViziLite Plus along with a standard oral cancer examination improves the ability to identify suspicious areas at their earliest stages. ViziLite Plus is a simple and painless examination that gives the best chance to find any oral abnormalities at the earliest possible stage. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. The ViziLite Plus exam will be offered to you annually. This enhanced examination by the American Dental Association code revision committee as CDT-2007/08 procedure code D0431; however this exam may not be covered by your insurance. The fee for this enhanced exam is $65.00. YES. I authorize the clinician to perform the ViziLite Plus exam along with the standard oral cancer examination. I accept financially responsibility for this enhanced examination. Print name: ______________________________________________________ Signature: ____________________________________ Date: ______________ NO. I would not prefer to have the ViziLite Plus exam at this time. Print name: _______________________________________________________ Signature: _____________________________________Date: ______________

STANDARD OF CARE In our continuing efforts to provide the most advanced technology and highest standard of care available to our patients, this practice is proud to announce the inclusion of the ViziLite Plus exams as an integral part of our annual and comprehensive oral screening program. One person dies every hour from oral cancer in the United States - and the mortality rate has remained unchanged for more than 40 years. Late detection of oral cancer is the primary cause as both the incidence and mortality rates of oral cancer continue to increase. Though tobacco use is a major predisposing risk factor, 27% of oral cancer victims have no lifestyle risk factors. According to the American Cancer Society, more women in the United States will be diagnosed with oral cancer this year (12,000 case) than will be diagnosed with cervical cancer (< 10,000 cases), and there are as many cases of oral cancer caused by the human papilloma virus (HPV 16/18), a sexually transmitted disease, as there are HPV-related cases of cervical cancer. Clinical studies have determined that using ViziLite Plus after the standard oral cancer examination improves the dental professional’s ability to identify and evaluate suspicious areas at their earliest stages. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. Proven screening technologies such as mammogram, Pap smear, PSA and colonoscopy offer the same type of early detection of cancer. ViziLite Plus is an easy and painless examination that gives this practice the best chance to find any oral abnormalities you may have at the earliest possible stage. Oral cancer risk by patient profile is listed below: Increased Risk: Patients age 18-39 and sexually active patients (HPV 16/18) High Risk: Patients age 40 and older; tobacco users younger than age 40 Highest Risk: Patients age 40 and older and lifestyle risk factors (tobacco use); patients with a history of oral cancer Dental insurance might not cover this advanced oral cancer screening as an addition to the standard visual examination. This practice prescribes the ViziLite Plus exam for all the patients at increased risk, high risk and highest risk for oral cancer (adult patients age 18 and older and tobacco users of any age). We will be performing the ViziLite Plus exam annually following the standard oral cancer examination of the oral cavity for a fee of $65.00

Dental Insurance Basics

This is our explanation and policy regarding dental insurance. Please read it and we will be happy to answer

any questions you may have. If you would like a copy, you will be provided with one. The Consent Form and

Financial Policy you sign states that this information has been provided to you.

Dental insurance isn't really insurance (a payment to cover a loss) at all. It is actually a money benefit typically

provided by an employer to help their employees pay for routine dental treatment. It is very different from

other types of insurance like medical, auto, life, and disability insurance.

Dental insurance is a contract between you or your employer and the insurance company. We will bill the

insurance company on your behalf as a courtesy. We estimate patient deductibles and copays as best we can

based upon the information provided to us by you and your insurance company. We give estimates of what

the insurance company may pay based upon what·we are able to verity. Estimated copays and deductibles are

due at the time of service. Any remaining balance due after the insurance company pays will be the patient's

responsibility and is due within 30 days of invoice. We will do our best to submit and collect payment in a

timely manner. However, outstanding insurance claims over 60 days will become your direct financial

responsibility. We will do our best to help you get reimbursement from your insurance carrier.

We will do everything possible to give you the very closest estimate of your "out-of-pocket" costs before

treatment is rendered. We understand that no one likes additional surprise costs. However, it is impossible to

always give perfect estimates of covered benefits because contracts between different employers or

individuals and the same or different insurance companies can have different payment percentages,

deductibles, exclusions, downgrades, alternative benefits, and unknown clauses that can alter these

estimates. Every written and verbal communication you or our office has with every insurance company will

include "there is no guarantee of payment".

The fee and payment estimates are for treatment decisions that are recommended by Dr Swain, and agreed

upon by you before any treatment is began. You will be given multiple treatment options that will address

your dental needs and that are offered in our office. The fees presented on your treatment plan are for the

treatment options that you choose. If our best payment estimates are not sufficient, we are happy to collect

payment in full up front and we will submit the claim with the assignment of benefits (payment) made to you

or you can file the claim yourself. We can also submit a pre-authorization to the insurance company that may

give more specific payment details, but this can delay your treatment. You can also call your insurance

company directly to verify benefits and request additional information

We do not accept assignment of benefits or auto insurance or worker's comp cases. These treatment costs

must be paid up front and directly by you, the patient. We will try to aid you in submitting a claim for

reimbursement.

Many patients are fortunate to receive benefit packages from their employer. Often these "perks" include dental insurance. The

following information will help you to learn more about your dental benefits and how they may assist you in paying for your dental

treatment.

Why are my dental benefits better than my spouse's even though they are both from the same insurance company?

Whenever your employer buys a dental insurance policy from an insurance company there are several things to consider, most

importantly cost. There are as many insurance policies as there are employers. The price of an insurance policy determines the level of

coverage you get. Insurance carriers sell "cafeteria" style policies allowing each employer to choose what will and won't be covered

and how much to pay for covered procedures. In other words you get what you pay for.

I have already used my $1500.00 in dental benefits and the year is not over. Shouldn't that money provide all the dental care I

need for a year?

Unlike medical plans, dental plans have a yearly maximum that your employer will pay out per year. Sadly, the average yearly

maximum has been the same since before 1960. There have been no increases for inflation or the rising costs of care in over 50 years!

If you have one or more teeth that need attention or it has been a little while since you have had dental care, it is unlikely that

$1500.00 will cover all needed expenses. Your dental insurance is meant to help off-set some of the cost of your care but is not meant

to cover all care even in the best of circumstances. Consider today's dental plans as a coupon for $1500.00 with multiple conditions for

redemption and an expiration date.

I need a cleaning 4 times a year but my insurance company will only pay for 2. Shouldn't the insurance company pay since it is

''clinically necessary" for me?

Another way for employers to limit their costs associated with dental benefits is to set up rules for how often procedures are to be

paid. Common examples of frequency limitations are 1 cleaning every 6 months and x rays 1 time per year. Dental policies are not

governed with the "clinically necessary" model used in medical policies but by the framework rules (frequency, quantity,

reimbursement levels) set by the employer when the policy was bought. These money-minded restrictions are not meant to sway the

patient away from needed services but to simply limit the employer's financial responsibility. Even if it is a procedure medically or

dentally necessary, it may be excluded from the contract.

How does my insurance company determine how much to pay on my dental claims?

When your employer bought your dental policy the price of the policy was calculated based on the “ceiling amount" the carrier would

pay for each procedure. The term the insurance carrier uses for this is UCR or Usual, Customary and Reasonable. An employer who

chooses to spend more money on a dental plan will have a more inclusive, higher percentile-paying policy resulting in less money

coming from the patient's pocket. It's easiest to think of UCR as negotiated payments for all covered procedures in your dental plan

that is tied to the cost of the premiums and your zip code.

I know all insurance policies are different but how do I know if my employers is worth the money?

A typical policy will normally pay at the following percentages of the Employer's Maximum Benefit Fee (not the dentist's actual fees):

100% (exams, x-rays, cleanings fluoride, sealants); 80 %( fillings, root canals, deep cleanings, extractions); 50% (crowns, bridges,

dentures). Currently, most policies pay about 65-70% for white fillings on back teeth due to a restriction called the Alternative Benefit

Clause that many employers adopt to limit plan costs. Approximately half of dental policies have some coverage for implants and

implant crowns. Most policies exclude coverage for tooth replacement if the tooth was missing before you went to work for your

employer and for cosmetic work including front tooth crowns and veneers.

Why does my insurance not pay for my entire cleaning visit even though it says it pays at 100%?

The 100% clause in your policy relates to 1OO% of the charge that your employer chose when the policy was bought rather than the

dentist's actual fee. The fine print in your dental policy will always read 100% of the ''Maximum Allowable Charge as Outlined in the

Plan Benefit Booklet". An employer can choose to lower the cost of a dental policy by choosing a lower percentile such as 70 or 80%.

The difference between what the insurance will pay on the employers’ behalf and the dentist's charge would be the patient's

responsibility rather than the employer's, thus lowering the employer's benefit plan costs.

My employer has several different dental benefit options. What is the difference between a PPO, DMO or an Indemnity

policy?

There are 3 types of employer provided insurance: PPO, DMO or Indemnity. A Preferred Provider Organization (PPO) is a type of

insurance that gives patients a choice as to where to have dental care. A patient may choose from the PPO list to find a provider that

has a contract with the insurance company or go to any dentist he or she chooses. The insurance policy rules and levels of

reimbursement are usually the same whether you use a network provider or not. The advantage is that the provider's fees are set by the

PPO insurance contract at a lower level and therefore the patient's co-pays may be slightly smaller.

A DMO or Dental Maintenance Organization is not a true insurance but a system where a patient is assigned to a dental office near the

patient's home or work. The patient is required to use that dental provider and in return receives dental care for co-pays or at

prearranged discounts. No claims are filed. If a patient needs to see a specialist, the assigned dentist determines necessity and gives a

referral to a contracted specialist. The model is very similar to the HMO model except that there are few dental providers that contract

with Dental Maintenance Organizations because the fees that insurance companies set for participating dentists are lower than the

actual cost of care. Therefore a patient's access to care is often reduced resulting in frustration and loss of use of the dental policy.

An Indemnity policy is similar to a PPO policy except that there is no network with which to contract. The patient chooses a dental

provider and the insurance company pays based on the rules set up for the policy.

I am self employed. Is there any good dental insurance for me?

Unfortunately, since dental insurance is an employee benefit that is funded by the employer, insurance companies do not offer those

types of policies to individuals. The insurance company is in business to make money. In order for an individual policy to be "money

making" to the insurance company, it must be paid more from the policy holder than it pays out in benefits. Therefore individual

insurance plans are usually "money-losing" for the patient. However, the government has recently passed some laws to help the self

employed. A health savings account (HSA) is an account with tax advantages in which you may set aside money for health and dental

expenses. Gilbert Smiles offers a 10% cash discount for those without dental insurance that pay with cash or check.

Why does my benefit plan only pay toward the least expensive alternative treatment?

To save money, many dental plans allow a benefit only for the least expensive method of treatment. For example your dentist may

recommend a crown with your insurance only offering benefit towards a filling. Dr. Swain will diagnose your treatment needs and

recommend options to best treat those needs. Our goal is to maintain or regain your best oral and overall health. We do not diagnose

based on cost alone. Dr. Swain will recommend the best treatment options for every patient like they are a family member or close

friend. Insurance companies pay as little as possible to make money.

What should I do if my insurance doesn't pay for treatment I think should be covered?

Because your insurance coverage is between you, your employer and the insurance carrier your dentist does not have the power to

make your plan pay. If your insurance doesn't pay you are responsible for the total cost of treatment. Sometimes a plan may pay if

patients send in their own claim. The Employee Benefits Coordinator at your place of business may help or you can appeal the

decision with your insurance company.