Patient Forms in Somerville, TN

Please print the patient forms below and complete them prior to your appointment. We appreciate your cooperation in helping us to provide you with prompt service.

Online Forms

Patient Name
Address
Gender
MM slash DD slash YYYY
Would you like text reminders?
May we contact you at work?
Emergency Contact Name

Dental HIstory

MM slash DD slash YYYY

Have you ever had a less than positive experience at the dentist?
If so, would you mind if the doctor asks you about that negative experience?
Do your gums bleed?
Do you use tobacco?
Are you happy with your smile?
Are you interested in whiter teeth?

Medical History

Are you taking a blood thinner such as Warfarin, Coumadin, Pradaxa, Xarelto, Plavix, Brilinta, Eliquis or Clopidogrel?
Have you ever taken or are you currently taking bisphosphonate drugs for osteoporosis such as Zometa, Reclast, Aredia, Fosomax, Actonel, Boniva or Didronel?
Have you ever taken or are you currently taking biologic type medication such as Humira, Enbrel, Prolia, Xgeva, Remicade or Avastin?
Have you ever received head/neck radiations? (NOT dental radiation)
Women, check which applies.
Are you allergic to:
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. I agree with the information listed above.
Signature
MM slash DD slash YYYY
I have been provided with a copy of Middlecoff Dental Group’s Privacy Policy.
MM slash DD slash YYYY

Cancellation and missed Appointment Policy

We always provide courtesy reminder calls, text or e-mails to remind you of you reserved appointment time. We ask that you confirm your appointment either by a return phone call, text or email. If we do not get a confirmation from you regarding your appointment, we reserve the right to remove your appointment from our schedule if that time is needed for another patient. If you just reschedule or cancel your appointment, we require 24 hours notice to avoid a broken appointment fee. The fee for a 1st broken appointment is $100, 2nd $125 and 3rd is $150. After 3 broken appointments we will only be able to see you on a walk-in basis if our schedule allows.

I agree with the information listed above.

Signature

Dental Insurance Information

Insurance filing and Financial Responsibility

As a service to our patients with insurance, Middlecoff Dental Group agrees to accept an estimated co-payment at the time service is rendered and bill insurance for the balance.

Even with our best efforts, we can only estimate what insurance will pay. We are never given a guarantee of coverage or benefits from your insurance carrier, and situations may arise when insurance will deny a claim or a portion of a claim when we submit it for payment. We will always restore teeth with tooth colored composite fillings since we feel that this type of restoration is far superior to silver amalgam fillings. Many insurance companies only pay for amalgam fillings. If this is the case, you will be responsible for the difference in cost between composite and amalgam.

Insurance is a contract between you and your carrier and if you have concerns, we strongly suggest that you contact your carrier prior to your visit.

IF insurance pays less than estimated or not at all, I agree to pay any amount not paid by my insurance to Middlecoff Dental Group. I authorize the release of any information necessary to process my claims. The information I have given is accurate and true to the best of my knowledge.

MM slash DD slash YYYY

Printable Forms

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Call us today at
(901) 466-0501
or complete the form below.

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