Are you a current patient?
The more we know about your past and present overall health, the better care we are able to give you. Please complete all the questions below. All responses are held in professional confidence.
Are you in a high risk group for AIDS? Yes No
Have you ever been told you have gum disease? Yes No
Female patients: Are you pregnant at the present time? Yes No
Are you satisfied with your mouth? Yes No
If you use recreational drugs, please let your doctor know before treatment begins.
(Type your name to sign electronically)
Payment in full is to be made each time services are rendered unless PRIOR arrangements have been made with the front desk personnel. We do accept Mastercard, Visa, Discover and American Express. Our main objective is to see that your dental needs are cared for. To avoid misunderstanding, please discuss financial arrangements prior to your appointment.
Dental insurance is a great aid for all of us. We will see that you get the very best dental care and will make every reasonable effort to aid you in obtaining the maximum benefits allowed with your insurance coverage; but please remember that the insurance company makes the rules on coverage – we don’t. We accept assignment of benefits on dental insurance as a courtesy to our patients providing:
Professional services are charged to the patient and not to the insurance company. The patient is responsible for payment of all charges regardless of the status of an insurance claim. We estimate what the insurance coverage will be to the best of our ability, but the patient is responsible for payment of any charges not paid by the insurance company.
This office is not responsible for ensuring that insurers reimburse patients under the terms of their insurance policies. Because the benefits belong to the insured patient, sorting out the terms of the policies is the sole responsibility of the policyholder.
Neeley – Nemeth, L.L.P., therefore, is not obligated (1) to effect, assure, or guarantee the collection of a patient’s claim filed under an insurance policy or (2) to participate in the negotiation of a patient’s settlement when claims filed under an insurance policy are disputed by one of the parties to the policy
In the event that there is a balance on your account, this office will send you an invoice for payment of that balance. All sums billed to you in this invoice will be due and payable at the office of Neeley-Nemeth, L.L.P., not later than thirty (30) days after the date on the invoice. You hereby agree that any balance not paid when due shall be delinquent and draw interest at the rate of twelve (12%) per annum, or the maximum lawful rate, which ever shall be less. You also agree to pay all costs of collection on your account, including attorney’s fees incurred prior to litigation and all costs and fees associated with such litigation. You also agree that Travis County, Texas, shall be the venue for such litigation.
Your appointment is specifically reserved for you, and we give great attention to coordinating appointments in such a way as to assure personal attention for every patient. It is, therefore, very important that you honor your appointment or notify us at least 24 hours in advance, if you need to change it. This courtesy will provide the opportunity to take care of other patients who need to be seen and will help us keep the costs of dental services for you as low as possible. Please be aware that, without 24 hours notice, you will be charged fifty dollars per missed appointment.
I have read the above policies and understand my financial responsibilities and agree to adhere to these policies.
I have received a copy of this office’s Notice of Privacy Practices.
When I see a picture of myself, the first thing I notice about my smile is:
Some things that I consider attractive in other people's smiles are:
Please select the statments beloe that apply to you.