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Disclaimer
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.
Patient or Guardian Signature *
To the best of my Knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Patient or Guardian Signature*
Dear Valued Patient:We look forward to seeing you at your upcoming appointment! Please complete the form below and review our new protocols.Your safety and the safety of our team is Omni Dental’s top priority. We will be closely adhering to the recommendations and guidelines that have been outlined by the CDC, OSHA and the Pennsylvania Dental Association (PDA). We ask that you assist us in protecting you and our team by kindly adhering to the following protocols at your next visit:-Please reschedule if you are experiencing any flu-like symptoms (cough, fever, etc.)-Please reschedule if you have had close contact with someone who has tested positive for COVID-19-Please arrive with a face covering -Please sanitize you’re hands prior to entry-Please do not bring anyone to your appointment who is not absolutely necessary-Please wait in your car and call us once you arrive (we will come out to your car to get you once your treatment room has been properly cleaned)-Please leave any unnecessary belongings in your car including jackets unless you would like to wear it during your appointment -Your temperature will be taken with a forehead thermometer upon entry. If you have a fever, you will be rescheduled 2+ weeks out. Please be advised that while our office complies with State Health Department and the Center for Disease Control and Prevention infection control guidelines to prevent the spread of COVID-19, we cannot make any guarantees. Our team is symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a number of screening questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.Please answer “yes” or “no”, to the following questions:1. Do you have a fever over 100.3°F?Yes No2. Do you have a sore throat or difficulty breathing?Yes No3. Do you have a cough?Yes No4. In the past 2 weeks, have you: Been in close contact with anyone who has COVID-19?Yes No5. Traveled outside of the U.S.?Yes No6. Been on a plane?Yes No7. If so, where have you traveled? Patient/Responsible Party Name & Signature:
Thank you for choosing Omni Dental! Our primary mission is to deliver the best and most comprehensive dental care available. An important part of this mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options:We accept payment in the form of: -Check, Visa, Mastercard, Amex and/or Cash -We offer a 10% courtesy discount for patients over the age of 60, who DO NOT have dental insurance, and who pay for their treatment with cash, check or credit card prior to completion of care. -Convenient monthly payment plans from both Care Credit and Alpheon Credit:
-For Care Plans totaling more than $3000 we offer additional financing optionsPlease note:Omni Dental requires payment prior to the beginning of your treatment. A fee of $75 is charged for patients who miss or cancel an appointment without at least 48-hour notice. There is also a fee of $75 for returned checks.If you have any questions, please do not hesitate to ask! We look forward to helping you meet your dental health goals and THANK YOU for trusting us with your care!!Patient, Parent or Guardian Signature:
Thank you for choosing Omni Dental! We will work closely with you to help you achieve your goals. While recognizing the benefits of a healthy mouth and a beautiful smile, you should be aware that dental treatment, like treatment elsewhere in the body, does have some inherent risks. These are seldom great enough to offset the benefits of treatment, however, they should be considered when making treatment decisions.Benefits of dental treatment can include: relief from pain, increased ability to chew properly, increased systemic health and a revitalizing feeling of confidence brought about by a pleasing smile. Nonetheless, some of the common risks associated with virtually any dental procedure are as follows:
Please note that our doctors follow strict procedural guidelines and would only make treatment recommendations that they believe are in our patients’ best interests. Thank you for trusting us with your care!I have read and understand the statement on this page. I have also been presented/read our notice of privacy practices form.
Omni Dental is committed to your lifelong dental healthOur doctors recommend treatment based on a comprehensive exam paired with your goals. We take your health seriously. We aim to offer you the very best in preventative, restorative and cosmetic dentistry. We believe that open communication fosters understanding, which is essential for us to successfully provide you with optimum care. Please take a few moments to review some of our policies and some frequently asked questions at our office. Thank you and we look forward to helping your reach your goals!48 Hour Cancellation Policy Appointments reserve your time as well as ours. In the occasion that you cannot avoid rescheduling an appointment, please advise us at least 48 hours prior to your appointment so that we may offer that time to another valued patient. A $75 fee will be assessed if 48 hours notice is not given to reschedule an appointment.Our Doctors Do Not Place Amalgam Restorations (Silver Fillings)Amalgam restorations can be very destructive to teeth as they are notorious for causing cracks that lead teeth to fracture. Additionally, amalgam fillings are very high in Mercury. Our doctors feel strongly that composite, tooth-colored fillings are the superior treatment for our patients, and therefore, we only offer composite fillings. It is important to note that some insurance benefits are based on the cost of amalgam fillings. “Regular” Cleaning Vs. “Deep” Cleaning (Periodontal Maintenance)A person who has had consistent dental care and has minimal signs or symptoms of gum disease will typically need a “regular” cleaning twice per year. If a person has not had consistent care, has periodontal disease (gum disease) OR has heavy calculus build-up (tartar), one or several “periodontal” cleaning appointments may be needed. Please note, we can only bill your insurance company for the type of cleaning you received. This means that you may not have the 100% coverage you expect if you need a “deep” cleaning.Payment Arrangements Prior to TreatmentWe accept cash, personal checks and most major credit cards as payment for services. In addition, we have outside financing options available. Accounts with a returned check will be charged a $75 returned check fee.Dental Insurance Is NOT Like Medical InsuranceMany people believe that dental insurance is like medical insurance, in that it will pay for most, if not all of your care. Unfortunately, this is not the case. The yearly benefit for most dental insurance companies has not increased since the 1980’s! This means that for some individuals, the most your dental insurance will contribute to your care is between $1,000 and $2,000 for the year. This might be sufficient if you have been staying up to date with your checkups, but for many people, especially those who have avoided the dentist, your dental insurance functions a lot more like a coupon. Here are few more things to note about dental insurance:
Please do not hesitate to ask us any questions about any of the information above (or anything else for that matter!). Your comfort is extremely important to us. Thank you for trusting us with your care!Patient/Guardian Signature:
Sleep & TMJ Questionnaire
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