Stephen B. Sexton, D.D.S. Scott A. Weiskopf, D.D.S.
(Please use blue or black ink No pencil)
Doctor you are seeing today: ____ Dr. Sexton ____ Dr Weiskopf
Patient Name:______Date of Birth : ______Age: _____
Last First (Legal) Middle
Address:______Sex: ____ Marital Status: ____
Street
______Height _____ Weight ______lbs.
City State Zip
Home Phone: ______Cell: ______Work: ______
Email address: ______
Social Security #: ______Occupation: ______
Employer & Address: ______
If Minor, Patient’s Guardian/Parent: ______Phone: ______
Guardian/Parent Address ______
Emergency Contact Name/Relationship: ______Phone: ______
Reason for This Appointment: ______
Who is your general Dentist: ______Who referred you to our office?______
PLEASE ANSWER ALL QUESTIONS
Please advise us of any (Or All) medical conditions Circle
1. Allergic to ANY medicines, foods or eggs? What? ______No Yes
______
2. Under the care of Physician? Why? ______No Yes
3. Taking any medicines? What? ______No Yes
______
______
4. Do you now take, or have you in the past taken Fosamax or Steroids (Cortisone) ______No Yes
5. Have you had any illness, operation, or been hospitalized in the past five years?______No Yes
6. Have you ever been put to sleep? ______No Yes
7. Do you now have a sore throat or cold? ______No Yes
8. Tobacco Use – Type? ______How long? ______How much daily? ______No Yes
9. Have you had: (Circle all that apply)
High Blood PressureBlood ThinnersSinus Disease Cancer/Tumors Artificial Joints/Valves
Low Blood PressureDiabetesPain Clicking of Jaws Rheumatic Fever Anemia
StrokeAsthmaSleeping or Snoring Problems Chest Pains Jaundice or Hepatitis
Heart AttackShortness of BreathRadiation Treatment Blood DiseaseGlaucoma
PacemakerLung DiseaseBleeding Problems ArthritisUlcers (Stomach)
Heart DiseaseEpilepsyThyroid Trouble Heart Murmur (MVP)
Kidney ConditionProblems with Immune System
Psychiatric or Chemical Dependency CareOther Illness:
10. Do you wear contact lens?______No Yes
11. (Women) Are you now pregnant? ______How many months? ______No Yes
12. Are you taking birth control pills? ______No Yes
Signature:______Date: ______
(if Patient is 18 or older, Patient must sign)
FINANCIAL RESPONSIBILITY
RESPONSIBLE PARTY(If Patient is under 18 years of age)
Name:______DOB: ______
Address (if different from patient) ______SS#: ______
Employer: ______Phone: ______Position: ______How long: ______
Work Address: ______
Spouse: ______DOB: ______
Employer: ______Phone: ______Position: ______How long: ______
Work Address: ______
INSURANCE INFORMATION
AS A COURTESY we will bill your primary and secondary insurance carrier if you provide all necessary information (such as insurance cards and/or completed and signed claim forms with their correct billing address).
Co-Pays will be collected ON THE DAY OF SERVICE.
We need all information filled out and will need a copy of Medical and Dental insurance cards.
(If we have received your insurance information prior to your appointment this form still needs to be filled out)
PRIMARY MEDICAL INSURANCE------
Subscriber Name: ______DOB ______Relationship to Patient ______
Subscriber SS# ______Subscriber ID# ______Group #______
Insurance Company ______Insurance companyPhone #______
Employer______
Claims Address ______
PRIMARY DENTAL INSURANCE------
Subscriber Name: ______DOB ______Relationship to Patient ______
Subscriber SS# ______Subscriber ID# ______Group #______
Insurance Company ______Insurance company Phone #______
Employer______
Claims Address ______
SECONDARYMEDICAL INSURANCE ------
Subscriber Name: ______DOB ______Relationship to Patient ______
Subscriber SS# ______Subscriber ID# ______Group #______
Insurance Company ______Insurance company Phone #______
Employer______
Claims Address ______
SECONDARY DENTAL INSURANCE ------
Subscriber Name: ______DOB ______Relationship to Patient ______
Subscriber SS# ______Subscriber ID# ______Group #______
Insurance Company ______Insurance company Phone #______
Employer______
Claims Address ______
1661 Aaron Brenner Drive, Suite 105
Memphis, TN 38120
Financial Policy
***Please be advised that there is a charge for consultation office visits and that payment in full is due at the time of service (Or we will file it to your insurance) ______
Initial
If you have insurance, we will file a claim to your insurance company on your behalf for services rendered in our office. However, at the end of 60 days, whatever balance exists on your account will be due and payable regardless of whether your insurance company has responded to our requests for payment or not. All unpaid account balances will be charged interest at the rate of 1.5% monthly (18% APR). Additionally, we do not know what your insurance will cover or how much they will pay toward covered services. Any amounts we ask you to pay on the day of service are ESTIMATESonly. We won’t know what insurance will pay until a claim has been filed and we receive payment. A $35.00 FEE WILL BE CHARGED FOR ALL RETURNED CHECKS.
* Please note, a current X-Ray is required for all consultation office visits (Dated one year or less)*
We will make every attempt on your behalf to have your insurance company pay toward the services you receive here, but please keep in mind that we don’t have a relationship with your insurance company. Any relationship that exists is between you and the insurance company. Therefore, we would advise you to contact your insurance company if you don’t receive anything in writing from them stating that they have paid on your account within 30 days as we file claims on the day your service is rendered.
***Also, please be aware that we are NOT network providers for all insurance plans. Therefore, you should check with your insurance company if you have any questions about your out of network benefits or how your insurance company will pay your claims in this office.
We gladly accept all major credit cards, Care Credit, Cash and cashier’s checks
**No personal checks.
Any balance on your account that is 90 days past due will be sent to an outside collection agency for further collection efforts. In the event that your account is placed with a Collection Agency, a collection-fee in the amount of 33% of the then outstanding balance may be added to your account and shall become a part of the total amount due. You will be responsible for any and all cost of collection including attorney fees and court cost.
You agree, that in order for us to service your account or to collect any amounts you may owe, we and our collection agencies may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We and our collection agencies may also contact you by sending text messages or emails using the email address you provide us to use. Methods of contact may include using pre-recording / artificial voice message and/or use of an automatic dialing device as applicable
______
Patient Name (Print) Patient/Guarantor Signature Date
1661 Aaron Brenner Drive, Suite 105
Memphis, TN 38120
Notice of HIPAA Compliance
I have been notified that Drs. Sexton and Weiskopf are in full compliance with the Federal Regulations for “Privacy of Individually Identifiable Health Information” as required by the “Health Insurance portability and Accountability Act” (HIPAA). I have been informed that a copy of the Federal and State Notice of Privacy Practices is prominently posted and I can receive a copy for closer review or to keep for my records upon request.
Print name of patient: ______
Date:______
Signature of patient or guardian: ______
Office Staff Witness: ______
Name of person/ persons that we can discuss your care and / or account with: