ACCEPTING NEW PATIENTS

250-339-2252

  • New Patient Questionnaire

 

Medical History

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No
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No
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No
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No
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No
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No
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No
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No
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No

Do you have, or have you had, any of the following? (Check all that apply)

Artificial joints, Valves or Prostheses
Anemia
Heart Condition
Abnormal Bleeding
Abnormal Bruising
Rheumatic Fever
High
Low
Controlled
Scarlet Fever
Fainting Spells
Liver Issues
Stroke
Kidney Issues
Epilepsy
Thyroid Problems
Arthritis
Tuberculosis
Diabetes Type 1
Diabetes Type 2
Hepatitis
A
B
C
Sinus Issues
Herpes
Asthma
STDS / STIs
HIV / AIDS Positive
Cancer
Radiation or Chemotherapy
Ulcers
Nervous Disorders
Blood Transfusion
Fibromyalgia
Acid Reflux
Cholesterol Issues
Vertigo
Depression
Anxiety

Personal Information/ All information is private and confidential

Yes
No

Please mark as you read each paragraph

APPOINTMENTS

I am aware that appointment times are reserved for me. If I am unable to keep an appointment I will give 2 business days' notice to avoid a late cancellation or missed appointment fee ($100/hr).

PERMISSION TO TREAT

This is to certify that I (the undersigned or guardian of a minor), consent to the performing of the dental and oral procedures to be necessary or advisable, including the use of local anaesthesia. I authorize the release of any records that are relevant to the processing and payment held by Dr. Nasralla Inc, to any appropriate health professional, licensing or regularity body for the purpose of administrative audit.

ESTIMATES

I am aware that any estimates given could change due to unforeseen circumstances and that I am responsible for any balance on my account.

Dental Insurance

You may not know this; dental insurance is an individual commodity. There are thousands of insurance companies and each company has thousands of individual group plans, each group plan is different from the next. There is no possible way a dental office would be able to know precise information about your dental plan. Dental offices are not directly connected to insurance companies, and now due to the privacy act (January 2004) most dental plans will not release information to the dental office. We must rely solely on our clients to give us the plan information. Some insurance companies will go so far as to only send the policy holder the information required by the dental office to submit your claims or for sending preauthorizations on your behalf.

Do you have Dental Insurance?

If yes, please provide the following information: Please note, we will not submit to any dental plan if we have not been given all the information requested. Also, there are a few dental plans that we will not accept assignment for: DIA, Healthy Kids, Ministry plans and Greenshield. However, we will do the paper work on your behalf.

Yes
No

Please check

I understand what I have read in regards to dental insurance, and realize that in the end I am responsible for my account balance with or without help from my dental plan

Our office will deal with your dental insurance one of two ways

(Please be aware that there are some dental plans that we will only deal with “Non-Assignment” and some plans that are set up by your employer to be “Non-Assignment”)

Option 1: “Non-Assignment” You (the patient) will pay the full amount of your dental appointment for each visit and we (the dental office) will do all the paper work and have your dental plan reimburse you directly. (On average dental insurance will reimburse you within 1-2 weeks)
Option 2: “Authorized Assignment” You (the patient) will pay in full any patient share owing for each appointment and we (the dental office) will submit all the paper work and wait for payment from your dental plan. In addition you will consent to authorize us to debit your credit card (which will be kept on file) for any balance owing that your dental plan declines to pay either in part or in whole.

*OPTION 2 ONLY AVAILABLE IF YOU ARE ABLE TO SUPPLY ALL NECESSARY INSURANCE AND CREDIT CARD INFORMATION!

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