New Patients

New Patients

We welcome new patients! Please fill out the Patient Information, and Medical History online forms" in New Patients page. Your information will be securely uploaded to our server. For questions or concerns, contact us at 248-398-1818
Teeth Cleaning — Beautiful Girl Smiling in Royal Oak, MI

PATIENT INFORMATION

RESPONSIBLE PARTY (if someone other than patient)

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION


MEDICAL HISTORY

Circle

LIST ALL PRESCRIPTION AND OVER-THE-COUNTER VITAMINS, NATURAL, HERBAL OR DIETARY SUPPLEMENTS

Other conditions Royal Oak Dental should be aware:


DENTAL HISTORY

PERSONAL HISTORY

BITE AND JAW JOINT

TOOTH STRUCTURE

GUM AND BONE

SMILE CHARACTERISTICS


PATIENT POLICIES

Thomas J. Gilbert, DDS

IMPORTANT POLICIES FOR OUR PATIENTS

Your Treatment

It is our experience that many difficulties can be avoided if all the parties involved are informed about what is expected.  Prior to undertaking any dental treatment you can expect us to inform you (a) why the treatment is necessary, (b) the various options to treat your particular dental problem and (c) the potential problems with any proposed treatment.  In turn, you will be encouraged to ask any questions you might have about the proposed treatment.


Payment

We also feel it is important that you understand our office policies and what is expected of you. Payment is expected at the time we provide services to you.  We accept personal checks, cash, Visa, MasterCard, and American Express.  Any checks returned due to non-sufficient funds will be subject to a $30.00 service charge.  We also accept Care Credit AND Lending Club for those who qualify.


Insurance

If you have dental insurance coverage, we are happy to bill your insurance company for you.  However for us to provide this service, we must have complete insurance information and confirmation of your coverage by your insurer.  Please inform us of any changes that occur in your insurance coverage.  We remind you that this is your insurance and it is in your best interest to have the most current insurance information.  We bill your insurance company as a courtesy to you, our patients.


After confirmation of our insurance coverage, you will be expected to meet your deductibles and pay those portions not covered by your insurance at the time our services are rendered, and before you leave our office.  Later, after claims are settled with your insurance company, any remaining balances must be paid within 30 days of settlement of those claims.  If a problem should arise, we are glad to provide your insurance company with any additional information necessary about treatment.


Accounts Receivable

We expect all balances to be cleared in less than 30 days.  All accounts receivable over 90 days will be assessed a finance charge of 5% per day.


Missed Appointment Policy

Appointments are scheduled for you and our professional staff and “chair time” are reserved especially for you.  Missed appointments and repeated tardiness are financial burdens to everyone.  After the first missed appointment, a standard office charge will be applied to your account.  If an appointment is cancelled less than 24 hours in advance, it will be considered a missed appointment.  Likewise, if you arrive late for your appointment, we may need to reschedule your appointment to another time or day, and it will be treated as a missed appointment.


We do confirm all appointments at least 24 hours in advance, but the ultimate responsibility for that appointment time is yours.  We offer appointment confirmation via email and text a few days prior to your appointment.  Please make sure we have your current email address and cell phone number on file in order for you to receive these reminders.

I HAVE READ THIS POLICY AND UNDERSTAND WHAT IS EXPECTED.


PATIENT CONSENT FORM

Thomas J. Gilbert, DDS

I understand that I have certain rights to privacy regarding my protected health information.  These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 


I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

-Treatment (direct or indirect treatment by other healthcare providers involved in my treatment)

-Obtaining payment from third-party payers (e.g. my insurance company)

-The day-to-day healthcare operations of our practice


I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. 


 I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.


I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions.  However, if you do agree, you are then bound to comply with this restriction.


I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

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