We understand that for many, an undesirable smile significantly influences self-confidence. It is our mission to deliver life changing smile enhancements in a pleasant and relaxing environment. With an unfailing dedication to scientific advances, technological developments, and superior skills, we are able to provide our patients with the finest dentistry possible.
Our approach to restoring smiles is always as conservative and non-invasive as possible. To deliver the ideal smile makeover, we take into consideration a clients unique facial form including their bone structure, skin and eye color, contour and shape of the lips, the gum shape and position, and of course, the teeth and how they all interrelate.
When we bring this all together, the results will have an affirmative impact on the overall appearance and self-confidence of the client. The outcome is always natural. We welcome you to our practice.
Patient information:
Patient’s Name (Last)__________________(MI)____(First)____________________
Address:______________________Apt:____City____________State____Zip_____
Social Security Number_______________________DOB:__/__/__
Employer_______________________Occupation____________________________
BusinessAddress___________________Suite_____City_____State______Zip_____
Home Phone Number: (___)________________Business Number:(___)__________
Mobile:(___)________________
How did you learn about us?_____________________________________________
**Please provide us with your e-mail address:
______________________@___________________
Office Policies:
All fees and insurance co-pays are due at the time of service. If payment cannot be met on the same day, for your convenience we offer payment plans through Care Credit. We do not bill any past due balances at anytime. If for one reason or another an account becomes delinquent over 60 days, we will forward the balance to collections or Care Credit Healthcare Financing (subject to credit). We hold the right to forward any outstanding balance to Care Credit first. At this time, you will be responsible for your balance within 12 months interest free. All financial arrangements must be made prior to treatment. Please inquire within before services are rendered.
A $25 service fee will be applied each month to your balance if third-party financing is not used; until the balance is zero.
All treatment is Non-Refundable at anytime. Consultations, Whitening pre-screening deposits, and laboratory serviced procedures are Non-Refundable at anytime.
All recall appointments must be met within no more than 6 months in order for laboratory work to be guaranteed. If this policy is breached, you will be responsible for the full cost of a laboratory re-make.
If changes need to be made to your scheduled appointment, please allow 24 hours notice. For appointments that are more than an hour please allow 48 hours to cancel or reschedule an appointment.
A fee of at least* $75 will be charged if less than 24-48 hours’ notice is given.
Elite Dental NYC has all the rights to amend or change any or all of its policies.
By signing this agreement you acknowledge that you have read, understand, and accept the above stated financial responsibility. You agree to all conditions stated above.
Signature ______________________ Date________________________
Continue Below Only If You Have Dental Benefits
Our practice is committed to offering the most superior treatment and services available. We believe you deserve the best care. We will always present you with the best dental solution possible to treat your personal situation.
Each year we provide outstanding care to hundreds of people. Some have dental benefits, but most don’t. If you have dental benefits, Congratulations! You are very fortunate.
Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits please contact your employer or insurance company directly.
You should know Insurance companies do not recognize many routine and new dental services. Dental benefit will never pay for the completion of your dental care. It is only meant to assist you
Primary Subscribers Information Self Other (please fill out information below)
Responsible Party’s Name (Last) _________________(MI)___(First)_____________
Address:______________________Apt.____City___________State_____Zip_____
Social Security Number_______________________DOB:__/__/__
Employer_______________________Occupation____________________________
BusinessAddress___________________Suite_____City_____State______Zip_____
Home Phone Number: (___)________________Business Number:(___)__________
Mobile:(___)________________Pager:(___)_____________Other(___)__________
Authorization of Payment to Elite Dental NYC
I authorize Elite Dental NYC, office of Dr. Thomas L. Lovetere to provide the above insurance company’s claim administrators and consulting health care professional’s information and diagnostic records concerning treatment provided and recommended to me. I hereby authorize payment of dental benefits other payable to me, directly to Elite Dental NYC. To the extent permitted under applicable law, I authorize release of any information relating to the claim. A photocopy of this document may act as an original.
Patient or Guardian’s Signature____________________________________Date____________________
GENERAL HEALTH & MEDICATIONS
Yes No Aspirin
Yes No Ibuprofen
Yes No Acetomenophen
Yes No Penicillin/Amoxicillin
Yes No Erythromycin
Yes No Tetracycline
Yes No Codeine
Yes No Local Anesthetics
Yes No Fluoride
Yes No Metals(gold, stainless steel, _______)
Yes No Latex
Yes No Other __________________
Yes No Are you required to take pre-medication before dental treatment? If yes, for what
condition__________________________
Female:
Yes No Taking birth control
Yes No Pregnant
Male:
Yes No Prostate disorders
List any medication, herbal supplements, and or vitamins take within the last two years
____________________________
____________________________
Please describe any current medical treatment,
impending surgery, or other treatment that may
possibly affect your dental treatment
____________________________
____________________________
Yes No Heart problems
Yes No High Cholesterol
Yes No Heart murmur
Yes No Rheumatic fever
Yes No High blood pressure
Yes No Low blood pressure
Yes No History of a stroke
Yes No Artificial prosthesis
(i.e. heart valve or joints)
Yes No Anemia
Yes No Prolonged bleeding due to slight cut
Yes No Emphysema
Yes No Tuberculosis
Yes No Asthma
Yes No Sinus problems
Yes No Kidney disease
Yes No Liver disease
Yes No Jaundice
Yes No Thyroid or parathyroid disease
Yes No Arthritis
Yes No Diabetes
Yes No Stomach or Duodenal ulcer
Yes No Digestive disorders
Yes No Glaucoma
Yes No Epilepsy or convulsions (seizures)
Yes No Hepatitis (type__________________)
Yes No HIV/AIDS
Yes No Radiation therapy
Yes No Chemotherapy
Yes No Tumor or abnormal growth
Yes No Any lumps or swelling in the mouth
Yes No Hives, skin rash, hay fever
Yes No Alcohol or Drug Dependency
Yes No Emotional Problems
Yes No Psychiatric treatment
Yes No Antidepressant medications
Yes No Often unhappy or depressed
Yes No Are you presently being treated for any illness
Yes No Aware of changes in your general health
Yes No Often exhausted or fatigued
Yes No Subject to frequent headache
Yes No Heavy smoker (1 + packs a day)
Yes No Head or neck injuries
Yes No Contact lenses
When was your last exam/cleaning? ________________________________
Please circle the level of fear you have about your dental visit
(1 none <->10 greatest fear)
1 2 3 4 5 6 7 8 9 10
Do you have any sensitivity? ____________________________________
Do you have any tooth pain? ____________________________________
Can you tell if your grind or clench your teeth? _______________________________
Ever whiten your teeth? ______________________________________
Please circle which type of toothbrush you use?
Soft Manual Hard Manual Electronic Toothbrush
Rate Your Smile (1-“I dislike my smile”<->10- “I love my smile”)
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