Patient Information Patient Name (Last, First, Initial): ,    Date E-mail Address: Soc Sec #: Date of Birth: Phone: (Home):    (Work):    (Cell):    Ext: Address: City, State Zip: , Health Information Date of Last Dental Visit: Reason for this visit: CURRENT MEDS: Have you ever had any of the following? Please check those that apply: AIDS Allergies Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes - A1C Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy Due Date: Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Thyroid Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy Others: Have you ever had any complications following dental treatment? Yes No If yes, please explain: Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain: Are you now under the care of a physician? Yes No If yes, please explain: Name of Physician: Phone: Do you have any health problems that need further clarification? Yes No If yes, please explain: Tobacco use / Vape? Yes No Do you require antibiotics prior to dental treatment? To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. Signature of patient, parent or guardian: Date: Signature of doctor _______________________________ Date: ________________   Referral Information Whom may we thank for referring you to our practice? Another Patient Dental Office Yellow Pages Newspaper School Work Other Name of person or office referring you to our practice: Spouse or Responsible Party Information The following is for: the patient's spouse the person responsible for payment Name: Sex: Male Female Marital Status: Married Single Child Other Social Security #: Birth Date: Address: City, State Zip: , Employment Information The following is for: the patient the person responsible for payment Employer Name: Occupation: Address: City, State Zip: , Insurance Information Primary Name of Insured: Is insured a patient? Yes No Insured's Birth Date: ID #: Group #: Address: City, State Zip: , Insured's Employer Name: Address: City, State Zip: , Patient's relationship to insured: Self Spouse Child Other Insurance Plan Name and Address: Secondary Name of Insured: Is insured a patient? Yes No Insured's Birth Date: ID #: Group #: Insured's Address: City, State Zip: , Insured's Employer Name: Address: City, State Zip: , Patient's relationship to insured: Self Spouse Child Other Insurance Plan Name and Address:   Consent for Services As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content. Signature of patient, parent or guardian Date: Relationship to Patient: Signature of guarantor of payment/responsible party Date: Relationship to Patient:   LDC Dental, LLC Leslie C. Flahaven, DDS 504 Lambs Road Pitman, NJ 08071 PATIENT CONSENT FOR USE AND DISCLOSUREOF PROTECTED HEALTH INFORMATION With my consent, LDC Dental, LLC may use and disclose Protected Health Information (PHI) about me to carryout Treatment, Payment and Healthcare Operations.Please refer to LDC Dental, LLC's Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing thisconsent. LDC Dental, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to LDC Dental, LLC, Privacy Officer at 504 Lambs Road, Pitman, NJ 08071. With my consent, LDC Dental, LLCmay call my home, cell phone or other designatedlocations, text my cell phone, email and leavea message on voicemail or in person in reference to any items that assist the practice in carrying out Treatment, Payment and Healthcare Operationssuch as appointment reminders, insurance items and any call pertaining to my clinical care. I have the right to pay out of pocket in full for treatment and instruct LDC Dental, LLCto refrain from sharing information about that treatment with my insurance company. With my consent, LDC Dental, LLC may mail to my home, e-mail or fax to a specified number or other designated locations any items that assist the practice in carrying out Treatment, Payment and Healthcare Operations such as appointments, reminder cards, pre-treatment information, dental claims and patient statements. LDC Dental, LLC will disclose to me any breach of unsecured protected health information. A separate authorization is required from me for LDC Dental, LLC to use or disclose any of my protected health information for marketing purposes. By signing this form, I am consenting to LDC Dental, LLC use and disclosure of my Protected Healthcare Information to carry out Treatment, Payment and Healthcare Operations. I also acknowledge availability to rereview and/or receiving a copy of LDC Dental, LLC Notice of Privacy Practices. I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not sign this consent, LDC Dental, LLC may decline to provide treatment to me. LDC Dental, LLC has my permission to discuss my Protected Health Information to carry out Treatment, Payment and Healthcare Operations with Patient Information Patient's Name Date Signature of Patient or Legal Guardian Phone Number Printed Name of Legal Guardian if NOT the Patient Email   LDC Dental Associates 504 Lambs Road | Pitman, NJ 08071 | (856) 589-2188 Written Financial Policy Thank you for choosing LDC Dental. Our primary mission is to deliver the best and most comprehensive dental care available. This service is based on a friendly team and professional understanding between our office team and patient. An important part of our mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options Cash, Check, Visa, Mastercard, American Express or Discover Card We offer an 10% courtesy accounting adjustment to patients who pre-pay for their treatment in full with cash or check or 5% courtesy adjustment for pre-payment in full with credit card. Convenient Monthly Payment Plans1 from Care Credit Allows you to pay over time No annual fees or pre-payment penalties Please note: LDC Dental requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case. For plans requiring multiple appointments, alternative payment arrangements may be provided. For patients with dental insurance, we are contracted with 8 insurance companies (Delta, Cigna, Assurant, United Concordia, Horizon Blue Cross/Blue Shield, Aetna, MetLife & United Healthcare.) We are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement for your treatment.2 Failure to pay in one of the above agreed upon manners (delinquent accounts) may be turned over to the collection agency. In this case, the patient is responsible for all costs associated with the collection procedure; including attorney fees where applicable. LDC Dental charges $15.00 for returned checks. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Patient Information Patient Name (Please Print) Date Patient, Parent or Guardian Signature 1 Subject to credit approval 2 However, if we do not receive payment from your insurance carrier within 90 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. Please enter code above in the field below.