Patient Forms - Benoit Family & Cosmetic Dentistry

Benoit Family and Cosmetic Dentistry and Treatment of TMJ Disorders

We are committed to excellence in dentistry and patient service. Thank you for 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 any assistance, please ask - We will be happy to help.

Who may we thank for referring you to our office or how did you find out about our office?

Name *

I prefer to be called by:

Sex

Male
Female

Marital Status

Single
Married
Child
Other

Date of Birth:

Social Secrurity Number

Home Address:

City:

State & Zip:

Home Phone:

Work Phone:

Cell Phone:

Email *

Can we contact you by email or cell for appointments?

Email
Cell

Employer:

How long there?

Occupation:

Employer’s Address:

City

State & Zip

PERSON RESPONSIBLE FOR ACCOUNT (if other than yourself)

Same as above

If different please fill out the following

Name:

Date of Birth:

Relation to Patient:

Billing Address:

City:

State & Zip:

Home Phone:

Work Phone:

Cell Phone:

Social Security Number

Employer:

Occupation:

SPOUSE INFORMATION (EMERGENCY CONTACT INFORMATION IF NOT MARRIED)

Name:

Date of Birth:

Employer:

Work Phone:

Home Phone:

Cell Phone:

Primary Dental Insurance

Insurance Company’s Name:

Phone Number:

Group Policy #:

Insured’s Name:

Insured’s Date of Birth:

Relation to Patient:

Insured’s SS #:

Insured’s Employer:

Insurance Card Upload

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload the front and back of your insurance card

SECONDARY DENTAL INSURANCE: PLEASE PRESENT CARD TO FINANCIAL COORDINATOR UPON YOUR VISIT TO OUR OFFICE.

MEDICAL HISTORY INFORMATION

Name of your primary care physician:

Do you have any other health problems that were not listed above?

Yes
No

If yes, please explain?

Are you now under the care of a physician?

Yes
No

If yes, please explain?

Have you been admitted to a hospital or need emergency care during the past two years?

Yes
No

If yes, please explain?

Are you taking any medications or herbal supplements (prescription or over-the-counter)?

Yes
No

If yes, please explain?

Are you allergic to any medications or substances (like latex)?

Yes
No

Please list:

Have you or do you use any type of tobacco product, and if you smoke, how many packs per day:

Yes
No

If yes, please explain?

Do you use any type of osteoporosis/osteopenia medications?

Yes
No

If so, please list:

Women: Are you pregnant:

Yes
No

Trying to get pregnant:

Yes
No

Nursing:

Yes
No

DENTAL HEALTH

Please help us better understand your dental health needs and goals by answering the following questions (check the best answer)

1) Have you had a complete set of X-rays in the last three years (this is a set of approx. 22 X-rays)

Yes
No

2) Fear of going to the dentist

Low
Moderate
High

3) My mouth and teeth are

Severe Discomfort
Moderate Discomfort

4) I am

Satisfied with the appearance of my teeth
Dissatisfied with the appearance of my teeth

5) I think my present state of dental health is

Excellent
Good
Fair
Poor

6) I would say that my main concern with my dental health is (are):

QUESTIONS FOR TMJ, BITE AND SLEEP CONCERNS

Do you have difficulty or pain opening your mouth?

Yes
No

Does your jaw get stuck or locked or goes out?

Yes
No

Do you have difficulty or pain when chewing or talking?

Yes
No

Are you aware of any popping, clicking, or noises in your jaw joints?

Yes
No

Do your jaw joints feel stiff, tight, or tired?

Yes
No

Do you have any pain in or around the ears, temples, or cheeks?

Yes
No

Do you have frequent headaches in the temporal area

Yes
No

Do you have a history of neck problems (whiplash injuries)?

Yes
No

Have you had any injuries to your head, neck, jaw, or chin area?

Yes
No

Are you aware of any recent changes in your bite (shorter, worn, loose)?

Yes
No

Have you been previously treated for bite, TMJ, or facial pain issues?

Yes
No

Do you have any problems eating or chewing bagels, power bars, or anything with substance?

Yes
No

Do you have problems when you chew gum?

Yes
No

Are you aware of any clenching or grinding issues at night or during the day?

Yes
No

Do you have arthritis?

Yes
No

Do you feel rested when you wake up in the morning?

Yes
No

Do you have any problems falling asleep?

Yes
No

Do you have any problems staying asleep?

Yes
No

FINANCIAL POLICY

We would like our patients to be informed of our office financial policy. We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive the maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy.

Payment is due in full at the time the service is rendered unless a previous arrangement has been made and approved by our financial coordinator. We accept cash, personal checks, Visa, Mastercard, American Express, Discover, and we have a financing option through Care Credit based on approval. Returned checks will be charged an NSF fee of $100.00. If the check is not settled with our office, it will be turned over to the Terrebonne Parish District Attorney’s office. If accounts become delinquent over 60 days and contact is either denied or not accepted by the patient or patient’s guardian, accounts will be turned over to our attorney for collection. Additional fees will be incurred.

If you have dental insurance, you must bring in your dental insurance card for proof of insurance and we will verify benefits in order to submit your insurance claim forms for you. However, you must realize:

1) Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.

2) We are not in network with any insurance companies. You as a patient can go to any dentist of your choice by law. We will still file your paperwork with your insurance company as a courtesy to you.
3) We cannot render services on the assumption that the charges will be paid for by the insurance company. All charges are your responsibility from the date of services are rendered.

4) Our fees are generally considered to fall within the acceptable range (U.C.R) by most insurance companies and therefore should be covered up to the maximum allowance determined by each carrier.

5) Not all services are covered in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

6) Remember: Please update our office staff regarding any changes to your dental insurance policy, so that we may process your claim in a timely manner.

7) In regard to usual and customary fees; the office of Brian J. Benoit, D.D.S. feels that we provide the highest quality care for our patients. Therefore, we feel our fees should reflect this. Usual and customary fees reflect “an average” and we feel that we go above and beyond this with our care and service.

APPOINTMENTS

We value your time, please value ours also. 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 scheduled appointment. If you find you must change an appointment, please provide us with at least 48 hours advance notification so that we may use that time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. A charge up to the full fee for the appointment value may be applied for a broken or missed appointment without adequate notification. We also ask that in order to schedule an appointment on Dr. Benoit’s schedule that you place a deposit down to reserve this appointment.

APPOINTMENT CANCELLATION POLICY

First of all, I would like to thank you for choosing Benoit Family and Cosmetic Dentistry and Treatment of TMJ Disorders. Over time, we have encountered last minute cancellations and patients who don’t show up. We ask you to please keep in mind, that when we make you an appointment, we are reserving a treatment room for you and only you to serve your individual needs. We value our patients and realize that your time is important. In return, we are asking for the same courtesy. That is why we are asking that if you must cancel or reschedule an appointment to PLEASE give us 48 hour’s notice. This courtesy makes it possible to give your reserved room and time to another patient. Therefore, effective immediately:

There will be a $50.00 charge for not showing up or rescheduling a hygiene/checkup 48 hours prior to your appointment. Also, for patients having any appointments for work done on Dr. Benoit’s schedule, the same will apply only the fee will depend upon the deposit made at the time of scheduling. Repeated cancellations or missed appointments will result in requiring a credit card to reserve future appointments.

We thank you in advance for understanding and once again thank you for choosing Benoit Family Dentistry. If you have any questions, please call the office at the following number: (985) 868-4681.

CREDIT CARD POLICY

Benoit Family and Cosmetic Dentistry has implemented a credit card policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurance has paid their portion and notified us of the amount that is your share. At that time, any remaining balance owed by you that is $500.00 or less will be charged to your credit card and a copy of your charges on a receipt will be mailed to you.

This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

Co-pays, coinsurance, and deductibles will still be due at the time of service. If you have any questions about this payment method, do not hesitate to ask.

I AUTHORIZE BENOIT AND FAMILY COSMETIC DENTISTRY AND TREATMENT OF TMJ DISORDERS TO CHARGE ANY OUTSTANDING BALANCES ON MY ACCOUNT TO THE FOLLOWING CREDIT CARD OR DEBIT CARD. (CHOOSE ONE)

VISA
MASTERCARD
AMERICAN EXPRESS
DISCOVER

DEBIT OR CREDIT CARD?

DEBIT
CREDIT CARD

ACCOUNT #

EXPIRATION DATE:

CODE ON THE FRONT OR BACK OF CARD:

NAME ON CARD:

BILLING ADDRESS:

Signature

Click and hold your mouse to draw your signature. If you are having trouble, try to right click and draw.

DATE:

AUTHORIZATION AND CONSENT

General Consent for Treatment

1) I agree to a dental examination by Dr. Brian Benoit. I understand that additional diagnostic procedures and dental treatment may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are:

Release of Information

1) I authorize Dr. Brian Benoit to release any information regarding my dental/medical history, diagnosis, or treatment to a third-party payors and/or other health professionals.

Assignment of Benefits

1) I authorize and request my insurance company to pay my benefits directly to Dr. Brian Benoit.

Photography Release

1) I authorize Dr. Brian Benoit 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 and presentations to better explain their options and educational programs.

Please complete the following fields and be sure to include your initials in the boxes. At the end of this page, please hold the right click and use your mouse to sign your name.

1) I understand and will comply with the office APPOINTMENT POLICY.

2) I understand and will comply with the office FINANCIAL POLICY.

3) I understand and will comply with the GENERAL CONSENT OF TREATMENT.

4) I authorize the RELEASE OF INFORMATION.

5) I authorize PHOTOGRAPHS to be taken of me and shown to other patients and for educational programs.

6) I have received a copy of the office’s NOTICE OF PRIVACY PRACTICES.

7) I understand and will comply with the office APPOINTMENT CANCELLATION POLICY.

8) I understand and will comply with the office CREDIT CARD POLICY.

I understand that Dr. Benoit is NOT IN NETWORK WITH ANY INSURNACE COMPANY but will file your insurance as a convenience. Per Louisiana law, you can still go to any Dentist you choose.

Upload your Driver's License

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Signature

DATE: