Affordable Family Dentistry

4440 Springfield Road #101, Glen Allen, VA 23060, 

804-217-9820

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

 

Excellence in

Family Dental Care

 
  

Patient Registration Information

Name (Mr./Ms./Dr.)_________________________________________

                                   First                      Middle                                       Last

Address __________________________________________________

________________________ 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______________

 

Insurance Information

Name of insured ___________________________________________

Date of Birth ____________ Social Security #____________________

Employer ___________________________ Work Phone___________

Address __________________________________________________

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

MEDICAL/DENTAL HISTORY

                                                                       


Patient’s Name___________________

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.

 

  1. What is the reason for your Dental visit?

______________________________________

 

  1. Please Check if you have any of the

    following? (Please Explain Below if any Checked)

 

  • AIDS/HIV
  • Allergies
  • Arthritis
  • Asthma
  • Bleeding Disorder
  • Blood Thinners
  • Cancer
  • Chemotherapy/Radiation/Tumors
  • Congenital Heart Defects/Heart Murmur
  • Diabetes
  • Fainting Spells or Seizures (Epilepsy)
  • Heart Disease/Heart Attack
  • Hepatitis/Jaundice/Liver Disease
  • High Blood Pressure
  • Joint Replacement
  • Kidney Trouble
  • Mental/Nervous Disorder
  • Pacemaker
  • Recently Any Unexpected Weight Loss
  • Rheumatic Fever/Heart Disease
  • Sexually Transmitted Disease
  • Stomach/Gastric Problems
  • Stroke
  • Surgery
  • Hospitalization for Any Illness
  • Premedication for Dental Treatment
  • Any Disease/Conditions No Listed

 

Explain:___________________________________

 _________________________________________

_________________________________________

 _________________________________________

  1. Physicians Name and Treatment being done:

_________________________________________

_________________________________________

 

  1. 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)

     _________________________________________

                  _________________________________________

  _________________________________________

  _________________________________________

  _________________________________________

  _________________________________________

  _________________________________________

  _________________________________________

 

  1. 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____________________________                       ( )

 

  1. Do you Smoke? _____________________

If yes:                                                                                                                                                __________/pack(s) a day

 

  1. Have you been on a drug or substance

     rehabilitation program?       ____________________                                                                                                                       

  1. Are you pregnant? (Females) (If yes, Due Date?)

__________________________________________

__________________________________________

 

 

 

 

 

 

 

____________________________                                        __________

Signature                                                                                                                                                                     Date

________________________________

If Minor Name of Guardian