Mandeville Form

We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please ask us - we will be happy to help.

Whom may we thank for referring you

Please provide your e-mail ID so we could send you a copy of this form

ABOUT YOU

Name:

I prefer to be called:

Male Female

Single
Married
Child
Other

Birth date:

Age

S.S.#:

Home Address:

City:

State:

Zip:

Home Phone:

( )

Work:

( )

ext:

Pager:

( )

Cell:

( )

E-mail Address:

Employer:

How long there?:

Occupation:

Employer's Address:

City:

State:

Zip:

PERSON RESPONSIBLE FOR ACCOUNT (if other than yourself)

Name:

Birth date:

Relation

Billing Address:

City:

State:

Zip:

Home Phone:

( )

Work:

( )

S.S.#:

Employer:

How long there?:

Occupation:

SPOUSE INFORMATION

Name:

Birth date:

Employer:

Work Phone:

( )

ext:

DENTAL INSURANCE INFORMATION

Primary Insurance

Insurance Co. Name:

Phone:

( )

Group/Policy #:

Insured's Name:

Insured's Birth date:

Relation

Insured's Social Security #:

Insured's Employer:

Secondary Insurance

Insurance Co. Name:

Phone:

( )

Group/Policy #:

Insured's Name:

Insured's Birth date:

Relation

Insured's Social Security #:

Insured's Employer:

APPOINTMENTS

We value your time, please value ours. Because we recognize the value of your time, you can expect us to see you at the appointed time and to keep your time spent in our office as short as possible. In return, when you make an appointment with us please be on time since we have reserved our time just for you. Also, please make every effort not to change your schedule appointment. If you find you must change an appointment, please provide us at least 48 hour advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. An hourly charge may be applied for broken or missed appointments without adequate advanced notifications. Thank you for your cooperation in this matter.

FINANCIAL POLICY

Unless another financial option is PRE-ARRANGED, payment in full is due the day of treatment.
For procedures longer than 1 HOUR, 1/3 down is expected to reserve the appointment time.

Payment Options

For your convenience we accept Cash, Check, Visa, MC, American Express and Discover.
We also offer short and long-term financing through Care Credit, Lending Club, and Proceed Financing
(12 months interest free financing may apply)

For patients with Dental Insurance

Patient chooses to pay in full for all treatment and will accept the offer from Mandeville Center for Dental Excellence to electronically file patients claim with the insurance carrier for direct reimbursement to the patient.

Patient agrees to pay a deposit for all treatment and will accept the offer from Mandeville Center for Dental Excellence to electronically file and accept payments from insurance carrier. Patient understands to receive this benefit, patient's credit card information will be needed to guarantee the account. Patient understands that as soon as the insurance carrier issues a payment, or 90 days, the unpaid portion of the claim will be charged to patient's credit card without penalty or interest. Patient understands that if for some reason the credit card is not available for covering the treatment balance, patient is responsible for payment with interest and penalties.

We are happy to help you file your insurance claims. Your insurance is a contract between you and your insurance company that we have no control over. Dr. Schof is not in contract with any insurance company. You are responsible for any balances that your insurance does not cover.

AUTHORIZATION AND CONSENT

General Consent to Treatment

I agree and consent to a dental examination by Dr. Schof. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed.

Release of Information

I authorize Dr. Schof to release any information regarding my dental/medical history,
diagnosis or treatment to third party payors and/or other health professionals.

Assignment of Insurance Benefits

I authorize and request my insurance company to pay my benefits directly to Dr. Schof.

Photography Release

I authorize Dr. Schof to take photographs of me to help me better understand my current dental condition and possible treatment options. I also authorize him to show these photographs to other patients to better explain their treatment options (as you may be shown photographs for the same reason)

My signature acknowledges that:

I understand and will comply with office Appointment Policy.
I understand and will comply with the office Financial Policy.
I understand and agree to the General Consent to Treatment.
I authorize the Release of Information.
I authorize Photographs to be taken of me and shown to other patients.
I have received a copy of the office's Notice of Privacy Practices.

Signature of patient, parent or guardian:

Clear

Date:

We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please ask us - we will be happy to help.

ABOUT YOU

PERSON RESPONSIBLE FOR ACCOUNT (if other than yourself)

SPOUSE INFORMATION

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY INFORMATION

MEDICAL UPDATES (for future use)

DENTAL HEALTH QUESTIONNAIRE

HEALTH LEVEL I - Emergency Care

HEALTH LEVEL II - Maintenance Care

HEALTH LEVEL III - Comprehensive Care

HEALTH LEVEL IV - Comprehensive & Cosmetic Care

APPOINTMENTS

FINANCIAL POLICY

AUTHORIZATION AND CONSENT

SCREENING QUESTIONS FOR BITE PROBLEMS

NOTICE OF PRIVACY FOR PROTECTED HUMAN INFORMATION

Charles A. Schof, D.D.S.

MICROBES&STRESS

CAUSES
of
Dental Disease

CLEANABILITY&STABILITY

OBJECTIVES
for
Optimum Dental

We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please ask us - we will be happy to help.

ABOUT YOU

PERSON RESPONSIBLE FOR ACCOUNT (if other than yourself)

SPOUSE INFORMATION

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY INFORMATION

MEDICAL UPDATES (for future use)

DENTAL HEALTH QUESTIONNAIRE

HEALTH LEVEL I - Emergency Care

HEALTH LEVEL II - Maintenance Care

HEALTH LEVEL III - Comprehensive Care

HEALTH LEVEL IV - Comprehensive & Cosmetic Care

APPOINTMENTS

FINANCIAL POLICY

AUTHORIZATION AND CONSENT

SCREENING QUESTIONS FOR BITE PROBLEMS

NOTICE OF PRIVACY FOR PROTECTED HUMAN INFORMATION

Charles A. Schof, D.D.S.

MICROBES&STRESS

CAUSES ofDental Disease

CLEANABILITY&STABILITY

OBJECTIVES forOptimum Dental

CAUSES
of
Dental Disease

OBJECTIVES
for
Optimum Dental