DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Patient registration

  • Chart Id:
  • Date:
  • First Name:
  • Last Name:
  • Middle Initial:
  • Address:
  • City
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  • Employer:
  • Work Phone:
  • Employer Address:
  • Home Phone:
  • Sex:
  • Male Female
  • Cell Phone:
  • Dob:
  • Age:
  • Email:
  • SSN:
  • Prefered Pharmacy:
  • Driver Lic:
  • Marital Status:
  • Single Married Widowed Separated Divorced

RESPONSIBLE PARTY (IF SOMEONE OTHER THAN PATIENT)

  • First Name:
  • Last Name:
  • Middle Initial:
  • Address:
  • City
  • State
  • Zip
  • Home Phone:
  • Primary Insurance Holder:
  • Yes No
  • Cell Phone:
  • Dob:
  • Age:
  • Work Phone:
  • SSN:
  • Email:
  • Driver Lic:


INSURANCE INFORMATION

  • Primary:
  • Secondary:
  • Name Of Insured:
  • Name Of Insured:
  • Relationship:
  • Dob:
  • Relationship:
  • Dob:
  • Insured SSN:
  • Insured SSN:
  • Insurance:
  • Insurance:
  • Employer:
  • Employer:
  • Policy Number:
  • Policy Number:
  • Group Number:
  • Group Number:

 

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you make be taking, could have an important interrelationship with the dentistry you will receive. Please answer the following questions so that we may treat you to the best of our ability. Thank you!

  • Are you under a physician's care now?
  • Yes No
  • If yes, explain:
  • Have you ever been hospitalized or had a major operation?
  • Yes No
  • If yes, explain:
  • Have you ever had a serious head or neck injury?
  • Yes No
  • If yes, explain:
  • Are you taking any medication, pills, or drugs?
  • Yes No
  • If yes, explain:
  • Do you take, or have you taken, Phen-Fex or Redux?
  • Yes No
  • If yes, explain:
  • Are you on a special diet?
  • Yes No
  • If yes, explain:
  • Do you use tobacco?
  • Yes No
  • If yes, explain:
  • Do you use controlled substances?
  • Yes No
  • If yes, explain:
  • Women Only:
  • Are you pregnant or trying to get pregnant?
  • Yes No
  • Taking oral contraceptives?
  • Yes No
  • Nursing?
  • Yes No
  • Are you allergic to any of the following?
  • Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Sulfa Drugs
  • Other:
  • Do you have, or have you had, any of the following?
  • AIDS/HIV Positive
    Alzheimer's Disease
    Anaphylaxis
    Anemia
    Angina
    Arthritis/Gout
    Artificial Heart Valve
    Artificial Joint
    Asthma
    Blood Disease
    Blood Transfusion
    Breathing Problems
    Bruise Easily
    Cancer
    Chemotherapy
    Chest Pains
    Cold Sores/Fever Blisters
    Congenital Heart Disorder
    Convulsions
  • Cortisone Medicine
    Diabetes
    Drug Addiction
    Easily Winded
    Emphysema
    Epilepsy or Seizures
    Excessive Bleeding
    Excessive Thirst
    Fainting Spells/Dizziness
    Frequent Cough
    Frequent Diarrhea
    Frequent Headaches
    Genital Herpes
    Glaucoma
    Hay Fever
    Heart Attack/Failure
    Heart Murmur
    Heart Pacemaker
    Heart Trouble/Disease
  • Hemophilia
    Hepatitis A
    Hepatitis B or C
    Herpes
    High Blood Pressure
    High Cholesterol
    Hives or Rash
    Hypoglycemia
    Irregular Heartbeat
    Kidney Problems
    Leukemia
    Liver Disease
    Low Blood Pressure
    Lung Disease
    Mitral valve Prolapse
    Osteoporosis
    Pain in Jaw Joints
    Parathyroid Disease
    Psychiatric Care
  • Radiation Treatments
    Recent Weight loss
    Renal Dialysis
    Rheumatic Fever
    Rheumatism
    Scarlet Fever
    Shingles
    Sickle Cell Disease
    Sinus Trouble
    Spina Bifida
    Stomach/Intestinal Disease
    Stroke
    Swelling of Limbs
    Thyroid Disease
    Tonsillitis
    Tuberculosis
    Tumors or Growths
    Ulcers
    venereal Disease
    Yellow Jaundice
  • Other
  • Comments:
  • To the best of my knowledge, the questions on this form have been correctly answered. I understand that providing incorrect information can be dangerous to my (or the patients) health. It is my responsibility to inform the dental office of any changes in my medical status.
  • Date:

 

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Questionnaire

  • Patient Name:
  • Date:

Please take the time to answer the following questions for us. This will help us to better understand and address each of your unique concerns.

  • 1. Were you referred to our office?
  • Yes No
  • 2. If so, who may we thank for your referral?
  • 3. When was your last professional cleaning and by whom?
    • a. Were there X-Rays taken at that time?
    • Yes No
  • 4. How often do you have your teeth cleaned?
  • 5. How often do you floss your teeth?
  • 6. Do you have sensitive teeth?
  • Yes No
  • 7. Do you have a history of gum disease?
  • Yes No
    • a. If so, have you seen a specialist?
    • Yes No
  • 8. How do you feel about dental visits?
  • RELAXED ANXIOUS NEUTURAL
  • 9. Tell us about your habits. Do you....?
    • a. Grind or Clench?
    • Yes No
    • b. Bite your fingernails?
    • Yes No
    • c. Smoke?
    • Yes No
    • If yes, how many per day?
    • d. Use smokeless tobacco?
    • Yes No
    • e. Use a hard toothbrush?
    • Yes No
  • 10. Do you or your partner snore?
  • YOU YOUR PARTNER BOTH
  • 11. Do you feel tired during the day?
  • Yes No
  • 12. Does your bite feel right?
  • Yes No
    • a. If no, please explain
  • 13. Do you wake up with headaches?
  • Yes No
  • 14. Do your jaw joints hurt?
  • Yes No
  • 15. Have you had Orthodontics (braces)?
  • Yes No
    • a. If so, who did them and when were they removed?
  • 16. Do you like the appearance of your teeth?
  • Yes No
  • 17. What about the appearance of your teeth bothers you?
  • Stains Chips or cracks Unattractive: Crowns or Bonding
    Color Length White or dark spots
    Spaces Crooked teeth Shape of teeth
  • 18. Would you like your smile to look 10 years younger?
  • Yes No
  • 19. Are you concerned about a receding gumline?
  • Yes No
  • 20. Do you want to have any missing teeth replaced?
  • Yes No
  • 21. Do you have any silver fillings that you would like to have replaced with new white bonded fillings?
  • Yes No
  • 22. Do you have teeth that you believe need porcelain veneers or all-porcelain crowns?
  • Yes No
  • 23. Would you like to learn more about invisible braces?
  • Yes No
  • Please tell us more about your dental goals:

 

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Acknowledgement of receipt
of notice of privacy practices

  • Date

I, , have received a copy of Dothan Cosmetic Dentistry NOTICE OF PRIVACY PRACTICES. I acknowledge that I understand the use of my private information for treatment and insurance purposes. I give my consent for Dothan Cosmetic Dentistry to file my information for me

If in case of emergency, please list a contact that we could call for you and explain any emergency:

  • Name:
  • Cell Phone:
  • Relationship to patient
  • Patient Signature:
  • Witness Signature:
  • ___________________________

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Statement Of Financial Responsibility

Assignment of Insurance Benefits I hereby authorize payment directly to Dothan Cosmetic Dentistry of all medical benefits otherwise payable to me or on my behalf for the treatment(s) performed and/or service(s) rendered at Dothan Cosmetic Dentistry. I understand any payment sent directly to me shall then be forwarded to Dothan Cosmetic Dentistry. I understand any unpaid deductibles, co-pays, or co-insurance amounts not payable by my insurance are my responsibility regardless of any pending insurance amounts. These amounts due from me are due on the date of service. This assignment of benefits is valid for insurance companies and programs.

By signing this form, you also acknowledge we are an out-of-network office with ALL insurance companies, we cannot guarantee specific coverage, and we can file your dental insurance ONLY if it has out of network coverage.

Authorization of Release of Information I authorize Dothan Cosmetic Dentistry to release any and all medical information concerning the treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistry as may be required by my insurance company in order to process payment of my claim(s).

Charges I understand that standard charges have been established for all services at Dothan Cosmetic Dentistry. I further understand that the fee(s) for my treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistry will be billed to my insurance company. If any additional treatment(s) and/or service(s) are deemed necessary by my physician, and performed today, those treatment(s) and/or service(s) will be billed to my insurance company as well.

Credit Policy Dothan Cosmetic Dentistry will file the appropriate claim forms to my insurance carrier. I will be notified when the final action (payment, denial, etc.) by my insurance carrier has been received. I understand that if my account becomes delinquent it will be placed with Prim and Mendheim LLC. Further, I agree to the following terms regarding any outstanding balance that I owe: (1) I will incur interest at the rate of 1 & 1/2 percent per month (18% per annum); (2) I agree and hereby consent that I will be responsible for reasonable collection costs, attorney's fees, and any court costs that are incurred by Dothan Cosmetic Dentistry in the collection of same, whether such outstanding balance is satisfied prior to, after initiation of a lawsuit, or after a judgment has been issued in a lawsuit; and (3) I agree and hereby consent that any lawsuit and/or legal proceeding surrounding the outstanding balance and debt, and fees and costs thereon, shall be initiated and litigated in the court of appropriate jurisdiction of Houston County, Alabama, and I hereby waive any and all defences and/or objections to said jurisdiction. I agree that if I have listed a cell phone number as a point of contact that I can be called at that number regarding my balance. Additionally, I agree to waive any and all state and/or federal personal property exemptions, wage exemptions, and/or homestead exemptions of my state of residence and/or state of operation in the event of judgment, levy, and/or garnishment. Further, if I reside in Florida or Georgia I agree to waive my rights to any exemption that would prohibit a wage garnishment should same become necessary to secure payment of any outstanding balance.

I, , have read and understand the terms of this policy statement.

  • Date
  • Patient's Signature (Parent or Guardian if Minor)
  • Date
  • Signature of Insured if other than Patient


DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Missed Appointment & Cancellation Policy

Missed appointments and last-minute cancellations adversely affect you, our other patients and our practice as a whole. It limits the availability of appointments for other patients and delays your treatment. We provide reminder calls and text prior to your appointment as a courtesy. For this reason, we expect that you will be responsible for remembering scheduled appointment times. If you must cancel or reschedule an appointment, please provide as much notice as possible with a minimum of 24 hours for regular appointments. Appointments that are greater than 2 hours in length require a minimum of 48-hour notification. Lengthy appointments are much harder to fill on short notice.

We understand that emergencies happen and will make allowances when appropriate. Failure to provide sufficient notice of cancellation, or not showing for your appointment without cancelling, will result in a $100.00 fee. Appointments that are scheduled in excess of 2 hours will be charged an initial $100.00 fee and then an additional $100.00 for each hour after the first 2 hours.

If you repeatedly cancel without adequate notice or reschedule the same appointment multiple times, you may be asked to pre-pay for appointments at the time they are scheduled. In cases where this becomes a chronic issue, Dothan Cosmetic Dentistry reserves the right to dismiss you from our care.

Arrival Time & Appointment Preparation

We appreciate your consideration in arriving for your scheduled appointment on time. If you are a new patient, you can find our new patient packet online at www.dothancosmeticdentistry.com. This can be printed out and completed prior to your appointment. If you are more than 10 minutes late this appointment will be considered a "no-show". Dothan Cosmetic Dentistry reserves the right to reschedule your appointment and a $100.00 fee will apply.
By signing below, I acknowledge the cancellation and arrival policy and will do my best to abide by them

  • Patient Name:
  • Signature
  • Date


DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D

Welcome to our practice

On behalf of my staff and I, we would like to welcome you to our office. We are pleased that you have selected us to care for all of your dental wants and needs. We would like for you to know that we are committed to providing you with the highest quality of oral health care in the most gentle, efficient and enthusiastic manner possible. We pride ourselves on making dentistry a pleasant experience for you, while providing you with the best dental treatment.

Do not settle for less than you deserve, A WORLD CLASS SMILE!

Our emphasis here at Dothan Cosmetic Dentistry is on early preventative care, but we also provide restorative and cosmetic services as well. For some, that may be Hollywood-style perfection. For others, it may be as simple as the confidence that comes with having brighter, whiter, straighter teeth. In some cases, a smile makeover can be realized in a few office visits. In many cases, however, "Short Term Orthodontics", a technique pioneered by Six Month Smiles, can straighten and realign crooked teeth in as little as six months. Cosmetic options include bonding, porcelain veneers and whitening. No matter how you define your "ideal smile", we at Dothan Cosmetic Dentistry are here to help you attain your vision and keep your smile healthy and beautiful.

Should you have any questions about our practice, services or policies, please do not hesitate to contact our office at 334-673-7440 or visit our website at www.dothancosmeticdentistry.com.

Sincerely,

Dr. Geoff Gaunt, D.M.D