1530 S Monroe Ave
Mason City, IA 50401
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–3:00 PM
Have you ever been a patient of our practice
Who will be responsible for the account?
Primary Dental Subscriber Gender
Primary Medical Subscriber Gender
Secondary Dental Subscriber Gender
Secondary Medical Subscriber Gender
The following financial arrangements are available.
Please indicate your choice of payment by checking Option A, B, or C.
We appreciate your understanding and cooperation in completing the following information. If you have any questions concerning our financial policies, please do not hesitate to ask for our office manager.
Payment is expected at time of treatment by
Note: If we are able to predetermine insurance coverage, you may know an estimate of your financial responsibility prior to surgery. If not, the exam fee cost and 20% of the total surgery/anesthesia/radiograph fee is due at the time of service. After your insurance company has made payment, the remainder of your balance is considered payable in full by you at that time. Options A (above) or C (below) are available to pay your balance. Any overpayment by you or your insurance company will be refunded after the account has been paid in full.
Check here if you would like preauthorization or a pre-treatment estimate of coverage from your insurance company. Also, please make this known to the receptionist or the doctor. We will be happy to take care of this for you.
FOR PATIENTS IN MANAGED CARE PLANS (INCLUDING MEDICAID [TITLE XIX]) WELLNESS
1. A copayment as directed by your managed care plan is required at the time of service.
2. Allowable charges for services not covered by your managed care plan are your responsibility. Options A (above) and C (below) are available for payment of those fees.
3. Medicaid (Title XIX) Wellness will not pay for your Panorex X-ray if one has been taken in the last 5 years. You will be responsible.
Patients wishing to finance treatment fees may be eligible for payment plans/financing through CareCredit. Please request details from the receptionist or office manager.
If 60 days have passed since your last payment, your account may be turned over to legal counsel and/or a collection agency for collection.
A processing fee will be charged to all accounts turned over to legal counsel and/or a collections agency.
A processing fee will be assessed to all accounts with returned checks.
Accounts with returned checks may be turned over to legal counsel and/or a collection agency for collection.
For the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential.
Are you under the care of a physician?
Are you taking any medications?
Do you take or have you ever taken or been given any of the following medications?
Are you allergic to or have you had a reaction to any of the following?
Penicillin or antibiotics
Barbiturates or sleeping pills
Aspirin or ibuprofen
Codeine or other narcotics
Latex or rubber products
Have you ever had any surgery, serious illness, or hospitalization in the past?
Have you or any family members had any serious reactions to IV sedation or general anesthesia?
Do you have or have you had any of the following diseases or problems?
Damaged Heart Valves, Artificial Valves, or Heart Murmur
History of Snoring, Sleep Apnea, or Use of CPAP
Rheumatic Heart Disease
Heart Attack, Heart Surgery, or Irregular Heartbeat
High Blood Pressure
Asthma, Hay Fever, or Allergies
Emphysema, Bronchitis, Etc
Do you have any blood disorders?
Abnormally prologned bleeding
Are you taking any blood thinners?
Have you ever required a blood transfusion?
Stomach Ulcer or Frequent Heartburn
Liver Trouble (Hepatitis, Jaundice, or Liver Disease)
Arthritis or Painful, Swollen Joints including Jaw Joint (TMJ)
Seizures (Epilepsy), Stroke, or Neurological Disorder
Any Disease, Drug, or Transplant Operation that has Suppressed your Immune System
Have you taken any steroid medications in the past two years?
Do you have any artificial joints?
Have you ever been treated for glaucoma?
Have you ever had treatment for a tumor or cancer?
Radiation therapy involving the mouth, face, or neck
Do you smoke or have your ever smoked?
Have you ever been treated for alcohol or other substance abuse?
Have you ever or you currently use any recreational/illicit drugs?
Have you had a cold, flu, sore throat, sinus infection, or other respiratory tract infection in the past week?
Do you have any other concerns or diseases you think the doctor should know about?
Do you wish to talk to the doctor privately about anything?
If you are using oral contraceptives, it is important to understand that antibiotics (and some other medications) interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.
Are you taking birth control pills?
Are you pregnant or trying to become pregnant?
Are you nursing (breastfeeding)?
ADDITIONAL DISCLOSURE AUTHORIZATION
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected healthcare information to the person(s) identified below. (I understand that the default answer is NO. Without indicating YES in answer to each individual question, personal protected healthcare information [PHI] cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
Any member of my immediate family
Any member of my extended family
Other Disclosure Party
The World Health Organization has characterized the COVID-19 virus, also known as "Coronavirus," as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.
COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.
Dental procedures can create fine water spray or "aerosols" which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.
To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.
I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.
I understand and accept the increased risk of COVID-19 exposure with treatment at this office.
I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.