New Patient

New Patient

Annapolis Periodontics


Practice Limited to Periodontics and Implant Dentistry
Angela M. Miele, D.M.D., P.C.
Deborah A. Odell, D.D.S.
Di Umoh, D.D.S., M.S.
Liz Polak, D.M.D., M.S.
888 Bestgate Rd., Suite #300
Annapolis, MD 21401
Office #: 410-224-0500 Fax #: 410-224-6039
annapolisperiodontics.net
PATIENT NAME:(Required)
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SEX(Required)
Marital Status(Required)
Address(Required)
Employer’s Address
Full Time Student
Has any member for your family ever been treated in our office?
Relationship to Patient
Name
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SEX
Policyholder’s Address
IS THE PATIENT COVERED BY DENTAL INSURANCE? If no, skip to next page(Required)
Address
Relationship to Patient
DOES THE PATIENT HAVE SECONDARY DENTAL INSURANCE? If no, skip to next page(Required)
Address
Relationship to Patient
Relationship to Patient
(Required)
Address
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MEDICAL HISTORY

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Physician Address/Location
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Are you now or have you ever been under a physician care?(Required)
Have you been out of the United States in the past 45 days?(Required)
Have you ever had to Pre-Medicate prior to a dental appointment?(Required)
Have you ever had or currently have the following conditions:
Do you smoke or use tobacco?(Required)
Check any of the following that you are taking or have taken:
Are you allergic to or do you suffer ill effects from any of the following?
FEMALE: Are you pregnant?(Required)
Breast Feeding?
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Acknowledgement Of Privacy Practices

My Signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Heath Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

  • Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers for my health care services
  • Conduct normal health care operations such as quality assessment and improvement activities.

    • I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices.

    I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide to such restrictions.
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Relationship to Patient

For Office Use Only:

We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due to the following reason:

  • The patient refused to sign
  • Communication Barriers
  • Emergency Situation
  • Other _______

Cancellation Policy

1. Cancellation / No Show Policy for Doctor Appointment $75.00

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, if an appointment is not cancelled at least 48 business hours in advance you will be charged a seventy five dollar ($75) fee for a missed hygiene visit.

2. Cancellation / No Show Policy for Surgery $250.00

If surgery is not cancelled at least three (3) business days in advance, you will be charged a fee of $250. This is NOT covered by your insurance company.

3. Account Balances

Patients with self pay balances are required to pay their account balances to zero (0) prior to receiving further services by our practice. Patients are encouraged to put a credit card on file for these payments. Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to an office manager with whom they can review their account and concerns. Patients with balances over $100 must make payment arrangements prior to future appointments being made.
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