Affordable Family Dentistry
4440 Springfield Road #101, Glen Allen, VA 23060,
Pain Free Tooth Extraction
Simple $100, Decayed $150
Surya P. Dhakar, D.D.S., P.C.
4440 Springfield Road Suite 101, Glen Allen, VA 23060
Patient Registration Information
First Middle Last
________________________ CITY _______________ZIP _________
Date of Birth ____________ Social Security # ___________________
Are you: Male Female
Are you: Married Single Divorced Widowed Separated
Home Phone _________________ Cell Phone ____________________
Work Phone _______________ e-mail address:___________________
Your occupation ________________ Employer:___________________
(If Minor, Parents Employer)
If you are a student, name of school/college ______________________
Emergency Contact: Name____________________ Phone______________
Name of insured ___________________________________________
Date of Birth ____________ Social Security #____________________
Employer ___________________________ Work Phone___________
Relationship to patient_______________________________________ Dental Insurance Company___________________________________
Employee I.D. Number_________________ Group #______________
Authorization, Release, and Financial Agreement
I (patient) hereby authorize and consent to dental treatment by Surya P. Dhakar, D.D.S., P.C.
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such dental care to third party payers, adjuster, attorney and/or other health practitioners.
I understand the risk and complications associated with local anesthesia and I consent to have local anesthesia as may be necessary during the dental treatment.
Due to the constantly changing insurance regulations, benefits, and deductibles, this dental office is only able to approximate MY balance or Co-pay on the date of service. I understand that my dental insurance may not cover the dental procedures and deny or pay less than the actual bill for services in such case I will be responsible for any remaining balance.
I agree that my final balance or co-pay be determined after receiving the insurance payment/explanation of benefits. I agree to be responsible for payment of all services rendered to me or my dependents. I authorize and hereby request my insurance co. to pay directly to the dentist for the dental services provided to my dependent or me. This office allows insurance company up to seven weeks to make payment to the office. If insurance does not pay for any reason with in seven weeks then I agree to be responsible for the full charges and pay this dental office immediately. I authorize you to file a complaint against Insurance Company on my behalf.
In the event that I fail to meet my financial obligations or default on payment, I agree to pay attorney or debt collection agency additional forty percent (40%) of the amount due at the time the account is turned over for collection plus court costs and any other expense incurred in collection. I also agree to pay 18 % per year finance charge on the unpaid balance from the date of service.
I realize that failure to keep this account current may result in Surya P. Dhakar, D.D.S., P.C. being unable to provide additional dental services except for dental emergencies.
Signature of patient ________________________ Date _____________
Surya P. Dhakar, DDS
Date of Birth: ___________________
A THOROUGH MEDICAL HISTORY IS AN IMPORTANT PART OF YOUR DENTAL RECORD. PLEASE ANSWER ALL QUESTIONS ACCURATELY, IT WILL ALLOW US TO PROVIDE YOU THE BEST POSSIBLE DENTAL TREATMENT FROM A FULLY INFORMED HEALTH PROFESSIONAL. IF YOU DO NOT UNDERSTAND ANY QUESTIONS, PLEASE ASK US.
- What is the reason for your Dental visit?
- Please Check if you have any of the
following? (Please Explain Below if any Checked)
- Bleeding Disorder
- Blood Thinners
- Congenital Heart Defects/Heart Murmur
- Fainting Spells or Seizures (Epilepsy)
- Heart Disease/Heart Attack
- Hepatitis/Jaundice/Liver Disease
- High Blood Pressure
- Joint Replacement
- Kidney Trouble
- Mental/Nervous Disorder
- Recently Any Unexpected Weight Loss
- Rheumatic Fever/Heart Disease
- Sexually Transmitted Disease
- Stomach/Gastric Problems
- Hospitalization for Any Illness
- Premedication for Dental Treatment
- Any Disease/Conditions No Listed
- Physicians Name and Treatment being done:
- Please list all the medicines you have recently
taken or currently taking: (including: antibiotics, sulfa drugs, anticoagulants, medicine for high blood pressure, tranquilizers, pain pills, insulin, tolbutamide, orinase, digitalis or drugs for heart trouble, nitroglycerin, antihistamine, oral contraceptive, hormonal therapy, any prescription or non-prescription drugs)
- Please Check any you are allergic to or have
reacted adversely to:
*local anesthetics ( )
*penicillin or other antibiotics ( )
*aspirin ( )
*iodine ( )
*codeine or other narcotics ( )
*metals ( )
*latex ( )
*other____________________________ ( )
- Do you Smoke? _____________________
If yes: __________/pack(s) a day
- Have you been on a drug or substance
rehabilitation program? ____________________
- Are you pregnant? (Females) (If yes, Due Date?)
If Minor Name of Guardian