Forms Output

Contact Information

Name:

Preferred Name:

Date of Birth:

Social Security Number:

Gender:

Email Address:

Phone:

Home: {{HomePhone}}
Mobile: {{MobilePhone}}
Work: {{WorkPhone}}

Mailing Address:

{{Address}}
{{City}}, {{State}} {{Zip}}

Referred By:

Family Dentist:

Doctor Name: {{FamilyDentist}}
Last Visit: {{FamilyDentistVisit}}
I do not have a family dentist: {{NoFamilyDentist}}

Emergency Contact:

Name: {{EmergencyContact}}
Relationship: {{EmergencyRelationship}}
Phone: {{EmergencyPhone}}

Preferred Pharmacy:

Name: {{Pharmacy}}
Location: {{PharmacyLocation}}
Phone: {{PharmacyPhone}}

Dental Insurance Information

Has Primary Insurance:

Another Responsible Party?

Subscriber Name:

Subscriber Date of Birth:

Subscriber SSN:

Subscriber Name:

Subscriber Relationship:

Subscriber Phone:

Subscriber Address:

Employer:

Group Number:

Claims Mailing Address:

Insurance Phone Number:

Payor ID:

Dental Insurance:

Company: {{DentalInsuranceCompany}}
ID: {{DentalInsuranceID}}

Has Secondary Insurance:

Another Responsible Party?

Subscriber Name:

Subscriber Date of Birth:

Subscriber SSN:

Subscriber Name:

Subscriber Relationship:

Subscriber Phone:

Subscriber Address:

Employer:

Group Number:

Claims Mailing Address:

Insurance Phone Number:

Payor ID:

Dental Insurance:

Company: {{SecDentalInsuranceCompany}}
ID: {{SecDentalInsuranceID}}

Medical Insurance:

Has Medical Insurance: {{MedIns}}
Company: {{MedicalInsuranceCompany}}
ID: {{MedicalInsuranceID}}

Another Guarantor?

Guarantor:

Mailing Address:

{{Address}}
{{City}}, {{State}} {{Zip}}

Date of Birth:

Medical History

What is your chief dental complaint?

If you could improve your current dental condition, what would you like to be done?

Have you had any serious trouble associated with previous dental treatment?

{{DentalTrouble}} – {{DentalTroubleMore}}

Would loss of your teeth be of great concern to you?

Are you wearing removable dental appliances?

How would you describe your overall health?

Height:

{{Height}}' {{HeightInches}}"

Weight:

{{Weight}} Lbs.

Do you have, or have you been treated for, any of the following conditions?

Anemia

Anxiety/Panic Disorder

Any Immune Disease

Arthritis

Asthma

Cancer/Tumors

Chronic Fatigue

Circulatory Problems

Depression

Diabetes

Emphysema/COPD

Epilepsy/Seizures

Excessive Bleeding

Fainting

Heart Condition

Heart Valve Replacement

Hepatitis

High/Low Blood Pressure

High Cholesterol

HIV/AIDS

Joint Replacement

Kidney Disease

Liver Disease

Low Blood Sugar

Lupus

Neurological Problems

Organ Transplant

Osteoporosis

Rheumatic Fever

Sinus/Respiratory Problems

Sleep Apnea/Snoring

Stroke

Thyroid Problems

Tonsilitis

Trauma to Head/Neck

Tremors

Tuberculosis

Ulcers/Gastric Reflux

Venereal Disease

Other conditions/major medical problems, serious illness, operation,
or hospitalization within the past 5 years (not listed above):

{{OtherConditions}}
No Other Conditions: {{NoOtherConditions}}

Current medications, vitamins, diet pills and/or natural remedies, narcotics:

{{Medications}}
No Medications: {{NoMedications}}

Allergies:

{{Allergies}}
No Allergies: {{NoAllergies}}

Are you taking/have you taken Bisphosphonates (Reclast, Fosomax, Atonel, Boniva, Aredia, Zometa)?

Physician:

Has A Physician? {{Physician}}
Doctor: {{DoctorName}}
Address: {{DoctorAddress}}

Do you smoke or chew tobacco?

Do you take any recreational drugs?

Do you drink alcohol?

Are you pregnant or trying to become pregnant?

Are you nursing?

Are you taking birth control pills?

Financial Policy

Are you pregnant or trying to become pregnant?

Agreed to the terms of the financial policy: {{FinancialAgree}}

Diagnostic Images

{{ImagesInit}}I understand ALL/ANY unpaid charges from insurance for images (3D Scans, Panoramic's, etc.)
taken and necessary for diagnostic purposes are ultimately my responsibility.{{ImagesInit2}}I understand any unpaid balances from insurance for Images or X-rays taken during my consultation will be my financial responsibility.{{ImagesInit3}}I understand there will be an interpretation of image fee for any X-rays not taken by Shelbourne & Associates.

Interpretation of X-ray range: $20 to $133
Panorex range: $66 to $133
3D Ct Scan: $235 to $519

HIPAA Privacy Policy

Are you pregnant or trying to become pregnant?

Acknowledged receipt of HIPAA policies: {{HIPAA}}

Release Authorization

Entity to Receive Information:

Spouse: {{release-spouse}}

Parent: {{release-parent}}

Other: {{release-other}}

Desciption of Information to Release:

No Restrictions: {{release-all}}
Appointment: {{release-appointment}}
Treatment Plan information: {{release-treatment}}
Financial: {{release-financial}}
Results of Lab Tests / X-Rays: {{release-results}}

Patient Rights:

I have the right to revoke this authorization at any time
I may inspect or copy the protected health information to be disclosed as described inthis document.
Revocation is not effective in cases where the information has already been disclosed, but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law

I permit Shelborne & Associates to release my information to any entities named above: {{release-allow}}

Medicare Opt-Out

Private Contract – Provider Opt-Out of Medicare

Provider Name: Shelbourne & Associates Oral & Facial Surgery:
Courtney Shelbourne, DMD, Miles Ware, DMD, Colleen Holewa, DMD

Provider Address: 1081 Johnnie Dodds Blvd, Mount Pleasant, SC 29464

Beneficiary Name

Legal Representative (if applicable)

Beneficiary Medicare Number

This private contract is between the physician and beneficiary noted above. The beneficiary is a Medicare Part B beneficiary and is seeking services covered under Medicare Part B. The physician above has informed the beneficiary or his/her legal representative they have opted-out of the Medicare Program. The current Medicare opt-out period is from 10/26/2024 to 10/26/2025. The Physician noted above is not excluded from participating in Medicare Part B under SS1128, 1156, or 1892 of the Act.

The beneficiary or his/her legal representative has read and agreed to the following terms of the private contract by placing their initials by the items below:

I, or my legal representative, accept full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by this physician/practitioner;

I, or my legal representative, understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner;

I, or my legal representative, agree not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare;

I, or my legal representative, have been informed of the expected or known expiration date of the opt-out period; which is 10/26/2024 to 10/26/2025;

I, or my legal representative, understand that Medicare payment will not be made for any items or services furnished by thephysician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a properMedicare claim had been submitted;

I, or my legal representative, enter into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out;

I, or my legal representative, understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare

I, or my legal representative, agree this contract was not entered into during a time when the beneficiary required emergency care services or urgent care services.

Submitted by {{FirstName}} {{LastName}} (Timestamp: {{__timestamp__}})

Thank you! Your submission has been received!

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New Patient Forms

Contact Information

Dental Insurance Information

Medical History

Financial Policy

Diagnostic Images

HIPAA Privacy Policy

Release Authorization

Medicare Opt-Out

Private Contract – Provider Opt-Out of Medicare