110 Professional Park Dr. Victoria, TX 77904

New Patient Packet

New Patient Packet

    Financial Arrangements & Policy

    Thank you for choosing our office for your dental health needs. Dr. Rainey, Dr. Fritsche and our team are committed to your treatment being successful and pleasant. The following is a statement of our Financial Policy which we ask that you read and sign prior to treatment.

    Our methods of payment accepted includes Cash, Personal Checks, Mastercard, Visa, and Discover credit card payments. We now offer Care Credit & Lending Club. Financing allows no interest payments for your dental care needs. If you have any questions, please feel free to ask.

    Initial

    • ________ Missed Appointments:
    Please be aware that when scheduled appointments are missed by either no-showing or without a 48 hours (2 days) notice, the patient’s account may be assessed a $100 fee. This fee is not covered by insurance, and will need to be taken care of prior to scheduling your next appointment. Thank you in advance for committing to your appointed time with us!

    • ________ Regarding Your Insurance:
    As a courtesy to you, we will help file your dental insurance. In order to help you, we will need to complete insurance information in order to bill your insurance company. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please understand that there are many different insurance plans. Payment is determined at the time the claim is received by the insurance company. Dental insurance is only meant to assist you, and not to pay for the completion of your dental care. We can only estimate what your insurance will help you cover. We do the best we can with the information the insurance company gives us. This is not a guarantee of payment. If your insurance company has not paid your account in full within 45 days, we require you to pay the balance in full by the methods above. In the event that your coverage changes, our office must be notified at least 2 business days prior to your appointment to ensure proper verification.

    • ________ Usual and Customary:
    Our practice is committed to providing the best treatment for our patients and we charge our usual and customary fees to all of our patients. Ultimately you are responsible for the payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Your policy may base its allowances on fixed schedule, which may or may not coincide with our usual fees. Usual and Customary fees by your insurance may be based from the average practitioner in an average office with average staff. We sincerely believe our office is far above those guidelines.

    The adult accompanying a minor and the parents (or guardians) are responsible for full payment.

    I understand and agree that all services rendered to me, my dependents, or others assigned by me to my account are charged directly to me. I further understand I am personally responsible for payment. Should the fees for the professional services not be paid in accordance with the provisions herein, applicable finance charges and disbursements, allowances and cost can be applied to all past due amounts at the rate of 1.5% per month (18% annual rate.) If the account is in default and turned over for collection, a collection fee will be added.

    name of patient (& parent/guardian)
    Signature & Date

    HIPAA OMNIBUS RULE

    PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

    You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.

    DATE: Will Be Automatically Filled from first step

    The undersigned acknowledges receipt of a copy of currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

    MY SIGNATURE WILL ALSO SERVE AS PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/ FACILITIES IN THE FUTURE.

    Please print name of Patient Please sign
    _______________________________

    Please list any other parties who can have access to your health information:
    (This includes step parents, grandparents, spouse, siblings or any care takers who can have access to the above named patient’s records)

    Name:
    Relationship:
    Name:
    Relationship:
    Name:
    Relationship:

    Patient No-Show and Cancellation Policy

    We strive to provide excellent and prompt dental care to all of our patients. In order to be consistent with this, we have adopted a Patient No-Show and Cancellation Policy for our office. When an appointment is scheduled, that time has been reserved for you. However, when you do not cancel or no-show to your appointment, it prevents another patient from getting much needed treatment.

    Our policy is as follows: You may cancel your appointment up to two business days before your scheduled appointment with no consequences. We will be happy to reschedule the appointment for you and leave the open time for another patient. If you miss your appointment or cancel less than two business days before your appointment, Comprehensive Family Dental will charge $100 for each no-show or late cancellation. This fee is the patient’s responsibility and is not billable to insurance.

    Additionally, if a patient is more than 15 minutes late to his/her appointment without prior notification, we reserve the right to cancel or reschedule the appointment.

    We do realize that, on occasion, emergencies or circumstances may arise beyond your control. We will address these situations with you should that occur.

    We thank you for working with us to ensure that we are able to provide the best service possible to all of our patients.

    I have read and understand the Patient No-Show and Cancellation Policy and I agree to the terms.

    Patient Name Printed: ____________________
    Date of Birth:
    Patient Signature: ____________________
    Date: ___________________________

    Patient PaperWork

    Last Name
    First Name:
    Middle Name:
    Preferred Name:
    Birthdate: Will be used from previous Step
    S.S#
    Patient Address:
    Email:
    Home PH:
    WK Phone:
    Cell Ph:
    Occupation/Grade/Major:
    Employeer/School:
    How did you hear about our office?
    Spouse's Name:
    Emergency Contact
    Phone:
    For All children (Under 18)

    Father's Name:
    Occupation:
    Work Ph:
    Father's Name:
    Occupation:
    Work Ph:
    Patient Lives With:
    Insurance Information

    Subscriber's Name:
    Birthdate: Will Be used from previous Step
    Social Security Number:
    Relationship to patient:
    Employer:
    Work Ph:
    Insurance Company:
    Insurance Company Ph:
    Member Id Number:
    Group Number:

    DENTAL HISTORY

    What is your reason for seeking dental treatment?
    What is your reason for seeking dental treatment?
    What was done then?
    Any Teeth Sensitive to?
    Do Your Gums Bleed?
    Does Food catch any place? Where?
    Do you have bad breath?
    Do you clench or grind your teeth?
    When:
    Prior orthodontic treatment?
    Were permanent teeth removed for orthodontics?
    Any soreness in your teeth or jaws on waking?
    Do you wear a nighttime appliance?
    Do your jaws click when you chew or open wide?
    Did you now, or have you ever had, pain in your jaw joint or the sides of your face?
    Do you like your smile?
    What would you change?
    Do you have any fear of having dentistry done?
    If yes, Why?

    PLEASE ANSWER EVERY QUESTION

    Have you (the patient) shown an allergy to, become sick from, or been told not to take:

    Other Medications
    Please list ALL medications you are taking (with or without a prescription):

    Have you been told that you should take antibiotics before all dental treatment?

    Alcohol Use?:
    Tobacco Use?
    Caffeine Intake?
    Have you been hospitalized or had a serious illness in the last three years?
    In your IMMEDIATE family, any history of ?

    (For women) Are you now:
    Do you get to sleep well, stay asleep well, and wake up feeling rested
    Has anyone ever said that you snore?
    Insomnia:
    Adenoids removed:
    Nasal Surgery:
    Tendency for ear infections:
    Stroke:
    Heart disorder:
    Heart pacemaker
    Chronic cough:
    Asthma:
    Osteoporosis:
    Fibromyalgia:
    Intestinal Disorders:
    Acid Reflux:
    Hepatitis or Liver disease:
    Epilepsy:
    Headaches:
    Glaucoma:
    Depression:
    Psychiatric care:
    Kidney problems:
    Hypoglycemia (High Blood Sugar):
    Sleep Apnea:
    Tonsils removed:
    Nasal allergies:
    Low blood pressure:
    High blood pressure:
    Heart attack:
    Valve replacement:
    Chronic pain:
    Immune system disorder:
    Anemia:
    Arthritis:
    Hemophilia:
    Vision impaired:
    Thyroid disorder:
    Cancer or tumors:
    Chemo or radiation treatment:
    HIV/AIDS:
    Muscular dystrophy:
    Hearing impaired:
    Prosthetic joint replacement:
    Diabetes:
    OTHER NOT LISTED:
    Previous Dentist’s Name:
    Phone:
    Physician’s Name:
    Phone:

    To the best of my knowledge, I have answered every question completely and accurately. I hereby agree to the use of any procedures, sedative analgesics or anesthetics as are deemed proper and necessary for dental treatment or diagnosis, and I authorize the use of any photos and video taken for the purpose of dental education

    I, Your Name Already Provided in previous step (patient),
    authorize Dr. Tim Rainey, Dr. Donnese Fritsche and Comprehensive Family Dental, to take photographs, and / or videos of my face, jaws and teeth, before, during and after treatment.

    I consent to allow the photos the be used for the following:
    ⦁ Dental Records
    ⦁ Dental Research
    ⦁ Dental Education including lectures, seminars, demonstrations, professional publications such as journal or books
    ⦁ Marketing material, including websites and printed materials, patient education

    I do NOT expect compensation, financial or otherwise, for the use of these photographs.

    Check here if you do NOT want your full face shot used for any of the above purposes

    Patient Signature:_________________________________________________
    Patient Birthday: Will Be Used From Previous Step
    Today’s Date: Will Be Used From Previous Step

    American Academy of Clear Aligners logo
    AADSM Qualified Dentist logo
    American Academy of Physiological Medicine & Dentistry logo
    American Dental Association logo
    Academy of General Dentistry logo
    Invisalign® Provider logo
    Comprehensive Family Dental Logo

    Our office is conveniently located off East Mockingbird Lane, between John Stockbauer Rd., and Sam Houston Dr.

    ADDRESS

    110 Professional Park Dr.
    Victoria, TX 77904

    HOURS

    Mon - Thu
    8:00AM - 5:00PM