Please upload your Photo ID

  Driver's License
Passport (Page with the photo and passport number)
Other Government issued Photo ID

PLEASE CAREFULLY READ BELOW:

I, THE UNDERSIGNED HEREBY AUTHORIZE THE DOCTOR TO TAKE X-RAYS, STUDY MODELS, PHOTOGRAPHS, OR ANY OTHER DIAGNOSTIC AIDS DEEMED APPROPRIATE BY THE DOCTOR TO MAKE A THOROUGH DIAGNOSIS OF THE PAITENTS DETERMINED NEEDS. I ALSO AUTHORIZE DENTAL COSMETIC CENTER OF EDISON TO PERFORM ANY AND ALLFORMS OF TREATMENTS, MEDCIATION THAT MAY BE INDICATED. I ALSO UNDERSTAND THAT THE USE OF ANESTHETIC AGENTS EMOBIDIES A CERTAIN RISK AND UNDERSTAND THAT MY DENTAL INSURANCE IS A CONTRACT BETWEEN THE INSURANCE CARRIER AND ME, AND BETWEEN THE INSURANCE CARRIERS AND DENTAL COSMETIC CENTER OF EDISON, AND THAT I AM FULLY RESPONSIBLE FOR ALL DENTAL FEES. THESE FEES ARE DUE PAYABLE AT THE TIME OF SERVICE. I ALSO ASSIGN ALL INSURANCE BENEFITS TO DENTAL COSMETIC CENTER OF EDISON. I FURTHER UNDERSTAND THAT AN ADDITIONAL CHARGE WILL BE ADDED TO ANY OVERDUE BALANCE. I HAVE READ AND UNDERSTAND THE NOTICE OF PRIVACY PRACTICE AS REQUESTED BY HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (“HIPAA”).

DENTAL COSMETIC CENTER OF EDISON
906 Oak Tree Avenue,Suite M,
South Plainfield, NJ  07080
908-222-3200
dental@dcc32.com

Patient Screening Form

Dental Cosmetic Center of Edison takes everyone's health very seriously. Recent Covid-19 pandemic has made it critical to screen patients before they come in and at the time of checking in at the office to protect everyone's health. We are following ALL necessary and recommended measures (which keep updating) as suggested by the state, CDC and other governing bodies to protect our staff and patients. Thank you for your understanding!

[FName] [LName]

Please select check box below.

*Do you/they have fever or have you/they felt hot or feverish recently (0-21 days)?

 Yes    No

*Are you/they having shortness of breath or other difficulties breathing?

 Yes    No

*Do you/they have a cough?

 Yes    No

*Any other flu like symptoms, such as gastrointestinal upset, headache or fatigue?

 Yes    No

*Have you/they experienced recent loss of taste or smell?

 Yes    No

*Are/Were you/they in contact with any confirmed COVID-19 positive patients in last 30 days?

 Yes    No

*Is your/their age over 60?

 Yes    No

*Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto - immune disorders?

 Yes    No

*Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

 Yes    No

Signature

INSURANCE DENTAL AND MEDICAL FORM

Do you have an ACTIVE PPO Dental Insurance ? YES  NO

*If YES Please fill each field

Upload Dental Insurance (Front) IF APPLICABLE
 
Upload Dental Insurance (Back)
 

Upload Medical Insurance (Front)  

Upload Medical Insurance (Back)
 

Name of Insured

Group Number

Insured Birth Date (mm/dd/yyyy)

Employer Name

Ins Company--Select Company--    3M Dental Services  Aarp Dental Ins. Plan C/O Delta Dental  Aetna Dental Plans  Ameritas  Anthem Blue Cross  Anthem Blue Cross  Assurant Employee Benefits  Assurant Health  Blue Cross  Blue Shield Of Oregon  Blue Cross And Blue Shield Of Alaska  Blue Cross Blue Shield Of Ca  Blue Cross Blue Shield Of Illinois  Blue Cross Blue Shield Of Massachusetts  Blue Cross Blue Shield Of Ok  Blue Cross Blue Shield Of Tx  Blue Cross Life And Health  Blue Cross/Blue Shield of Hawaii  Blue Shield Of California  Blue Shield Of California  Blue Shield Of California  Blue Shield of California  Blue Shield Of California  Carrington  Cigna  Delta Dental  Delta Dental Aarp  Delta Dental Healthy Families  Delta Dental of Arkansas  Delta Dental Of Arkansas  Delta Dental Of California  Delta Dental Of California/Tricare Retir  Delta Dental Of Colorado  Delta Dental Of Florida  Delta Dental Of Hawaii  Delta Dental Of Illinois  Delta Dental Of Iowa  Delta Dental Of Kansas  Delta Dental Of Kentucky  Delta Dental Of Massachusetts  Delta Dental Of Michigan  Delta Dental Of Minesota  Delta Dental Of Missouri  Delta Dental Of New Jersey  Delta Dental of Oregon  Delta Dental Of Pennsylvania  Delta Dental Of Rhode Island  Delta Dental Of Tennessee  Delta Dental Of Wisconsin  Dentemax/Surency  Dentical  Direct Reimbursement Dental Plans Of Ny,  Geha Connection Dental Federal  Golden West Dental  Great-West Healthcare  Group Administrators Ltd.  Guardian  Health Partners  Humana Dental  Humana Dental  Life Wealth Management  Lincoln Financial Group  Lincoln Financial Group  MetLife  National Elevator Industry Benefit Plans (NEIB)  Northeast Delta Dental  Premera Blue Cross  Premier Access Insurance  Principal  Reliance Standard (Asrm)  Safeguard  Samba  Sun Life Financial  United Concordia  Washington Dental Service  Other  

If OTHER insurance please enter name here:

I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.

DENTAL COSMETIC CENTER OF EDISON
906 Oak Tree Avenue,Suite M,
South Plainfield, NJ  07080
(908) 222-3200
dental@dcc32.com


Cancellation/Late show/No Show Policy

1. We require 1 business day (24 hour notice) if you are unable to make your appointment.
2. There will be a $50.00 fee for any missed appointments without 24 hour notice. Dental Cosmetic Center of Edison, will charge your credit card on file for the date of cancellation/late show/no show. We make every attempt to remind a patient of their appointment but untimately, it is YOU who is responsible for your appointment.
3. If more than 10 minutes late for your appointment without notice, you will be considered a no-show and be charged $50.00.
4. You will not be seen if you are more than 10 minutes late for your appointment unless we are able to accommodate you later during the day otherwise your appointment will need to be rescheduled for another day.

Patient's Signature,