New Patient Information Form - DS Family and Cosmetic Dentistry

  • New Patient Form

    Dr. Daniel C. Sluyk, DDS
  • Gender
  • Family Status
  • Birth Date*
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  • Date of Last Dental Visit*
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  • Format: (000) 000-0000.
  • Check all of the following that you may have had in the past or that currently apply to you:
  • Are you allergic to or have you reacted adversely to any of the following medications? Please check all that apply.
  • Have you ever taken any of the following medications? Please check all that apply, and provide start/end dates.
  • Please describe your present health
  • Are you a past or present smoker/vaper?
  • Do you have any history of substance abuse, or do you currently use recreational drugs?

  • The above information on this form has been accurately answered and is true to the best of my knowledge. I understand that providing incorrect information can be dangerous to my or the patient’s health. I understand that it is my responsibility to inform Dr. Daniel C. Sluyk, DDS of any changes in my or the patient’s medical status.

     
     
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  • Primary Dental Insurance

     
  • Format: (000) 000-0000.
  • Insured's Birth Date
     - -
  • Patient's Relationship to insured

  • Secondary Dental Insurance

     
     
  • Format: (000) 000-0000.
  • Insured's Birth Date
     - -
  • Patient's Relationship to insured
  • Insurance Authorization - please complete for payment of insurance benefit

  • Dental Information

  • How would you rate the condition of your mouth?
  • How often do you routinely see your dentist?
  • Personal history, check all that apply:
  • Smile Characteristics, check all that apply:
  • Bite and Jaw Joint, check all that apply:
  • Tooth Structure, check all that apply:
  • Gum and Bone, check all that apply:

  • Financial Policy

    As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for all costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.
    All payment is due in full at check-in on the day of service. We accept all major credit cards, cash, check, CareCredit and Lending Club.
    All emergency services, or any services performed without previous financial arrangements must be paid for in full at the time of service unless other arrangements have been made. All appointments with Dr. Sluyk and Lifeguard Sedation must be paid for in full before scheduling, no exceptions.
     
    DENTAL INSURANCE
    Patients with dental insurance understand that all services are charged directly to the patient and that he or she is personally responsible for the payment of all dental services. All estimate amounts are based solely on available insurance breakdown information, are not a guarantee of benefits, and are provided by our staff purely as a courtesy to our patients. Estimated patient cost amounts shall be collected no later than check-in on the day of treatment.
    Our office will bill patient insurance as a courtesy. However, Dr. Sluyk cannot render services on the assumption that our charges will be paid by an insurance company. If the insurance carrier pays less than estimated, the patient is responsible for any unpaid balance. Treatment estimates are valid for a period of six months.
     
    USUAL AND CUSTOMARY RATES
    Our practice is committed to providing the best care for our patients. We charge what is usual and customary for our area. Patient is responsible for payment regardless of any non-contracted insurance company's arbitrary determination of usual and customary.
    A service charge of 1.5% per month (18% per annum) on any unpaid balances will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
    In consideration of the professional services rendered to me by this practice, I agree to the above financial policy. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due.

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  • Cancellation Policy

    MISSED APPOINTMENTS
    Should you need to cancel or reschedule your dental appointment, appropriate notice must be given as soon as possible. This gives Dr. Sluyk and his team adequate time to schedule other patients who may be waiting for an appointment.
    All appointment cancellations and/or reschedules outside a window of two (2) business days (48 business hours) shall result in a $50 late charge per hour scheduled. Notice may not be given by email, voicemail, or text message, and must be confirmed with a staff member to complete cancellation process. No exceptions.
    Please help us serve you better by keeping scheduled appointments and by giving us as much advance notice of cancellation as possible.
     
    LATE ARRIVAL
    If patient arrives later than 15 minutes from the scheduled appointment time, this is considered a No-Show and shall fall under the same policy listed above, no exceptions.
     
    DR. SLUYK & LIFEGUARD ANESTHESIA SEDATION APPOINTMENTS
    All appointment cancellations and/or reschedules for sedation appointments must be made within two (2) business days (48 business hours) of scheduled appointment. Notice may not be given by email, voicemail or text message, and must be confirmed with a staff member to complete cancellation process. No exceptions.
    If proper notice is not given, a $50 late charge per hour scheduled shall be applied. Additionally, all pre-payment toward sedation services shall be forfeited, and must be re-collected to reschedule future sedation services. The rate for Lifeguard Anesthesia services is currently $650/hour scheduled. No exceptions.
    Thank you for understanding our Cancellation Policy. Please let us know if you have questions or concerns.
    By signing below, I have read, understand, and agree to the Cancellation Policy.

     
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  • HIPAA Acknowledgment

    I understand that I may inspect or copy the protected health information described by this authorization.

    I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records who release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my health care will not be affected if I refuse to sign this form.

    I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

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  • Informed Consent for Local Anesthesia

    I understand that my dental treatment may require the use of a local anesthetic for pain control. I understand that a local anesthetic may consist of different medications that are injected into the cheek, jaw, or gum area. These drugs may include lidocaine, prilocaine, mepivacaine, bupivacaine, articaine, or others. I understand that local anesthetics may contain a “vasoconstrictor” like epinephrine; antioxidants, such as sulfites or methylparaben for preservation of the solutions; sodium hydroxide, and sodium chloride.

    I understand that local anesthetics will cause a section of my mouth to become numb, with the numbness lasting up to several hours. I know that while my mouth is numb, I must be careful not to bite my lips or tongue.

    Local anesthetics are among the most common drugs used in a dental office. Complications and side effects are rare, but may include, among others not listed below:

    • Swelling, bruising, or soreness at the injection site
    • A blood-filled swelling called hematoma, can form when a needle used during an injection hits a blood vessel
    • Temporary numbness outside of the mouth making an eyelid or mouth “droop”
    • Temporary rapid heartbeat
    • Damage to the nerves resulting in temporary or possibly permanent numbness or tingling of lips, chin, tongue or other areas
    • Severe and possible life-threatening allergic reactions necessitating emergency care

    I understand that if I have uncontrolled high blood pressure, uncontrolled thyroid problems, angina, or have recently had a heart attack, I will inform my dentist without fail as these conditions have caused complications for persons receiving local anesthesia. I will also inform the dentist of any prescription or over-the-counter medications I am taking as these may interact with local anesthetics. I understand my dentist’s recommendation of local anesthetic for all the dental procedures that requires adequate pain control, risks of the local anesthetics, any alternatives and risks of these alternatives, including consequences of doing nothing. This consent for local anesthetic remains valid every time I seek any treatment in this office. I have had all my questions answered and have not been offered any guarantees.

     
     
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  • Social Media & Photography/Video Consent

    I agree to grant the following rights and permissions to Dr. Daniel Sluyk to take full-face photographs and/or video images of me for marketing purposes. I understand my photographs will be used specifically for, but not limited to, advertisement purposes, print media and distribution over the internet for illustration, promotion, art, editorial advertising, trade, or any other purpose whatsoever.

    I hereby warrant that I have the right to contract in my own name. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents of this document.

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  • Consent for Internet Communications

    I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purpose, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to activate my ID due to security concerns.

    I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

     
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  • Add a Card on File

    To ensure your appointments are securely booked, we require a credit card on file. This measure is enforced according to our financial policy to address late cancellations or rescheduling.

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