- Dr. LuAnne M. Curatola
Dr. Joseph A. Zagami
Patient Information Health History
Welcome to our practice:
Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We look forward to working with you to maintain a healthy, happy smile.
- What is your current gender identity? (Check ALL that apply)
- (for insurance purposes) What sex were you assigned at birth? (Check one)
Please make sure that the information given is for you dental insurance, not medical. They are often administered by different insurance companies. Check with you Benefits Coordinator if you are unsure.
| Please enter any information not covered by image below:
- Mailing address of claims
- Mailing address of claims
Please check if you have had any of the following:
- Have you been Hospitalized or under the care of a medical doctor during the past 2 years?
- Are you currently taking any medications or drugs? (including regular doses of over-the-counter medicines, vitamins and supplements
- If Yes, please list:
- Women: Are you pregnant or think you may be pregnant?
- Are you taking birth control pills?
Are you aware of having an allergic (or adverse) reaction of the following:
Patient Acknowledgement and HIPAA Update, please read and sign below:
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been
answered to my satisfaction. I will not hold my dentists or any other member of their staff responsible for any errors or omissions that I may
have made in the completion of this form.
In an effort to comply with Federal Privacy Practices, please read and sign below:
I certify that I am aware of the Federal Privacy Practices, and/or have been given a notice of such from the office of Drs. Curatola & Zagami. I
understand that I will receive postcards, letters, internet correspondences, and phone calls at any of the contact information I provide to this
practice. I also understand that I must personally notify the practice should I not wish to receive any of the above correspondences or
- What type of tooth brush do you use?
- Do you ever feel (or have you ever been told) that you don't have fresh breath?
- Which types of food cause you twinges of pain
- Do your gums feel tender or swollen?
- Do you have any cold sores / mouth sores / mouth ulcers?
- Do you clench or grind your jaws while sleeping or during the day?
- Do your jaws ever feel tired?
- Do you still have your wisdom teeth?
- Do you snore when sleeping?
- Have you ever been diagnosed with Sleep Apnea?
- Have you ever been treated for any of the following?
- Would you like to have whiter teeth?
- Would you like to have straighter teeth?
- If you could change any thing about your smile, what would it be? (please check any of the following that apply)
Scheduling and Cancellation Policy
Our practice is dedicated to the highest quality care and exceptional patient service. Our doctors and staff spend extensive amounts of time preparing for your visit. Broken and missed appointments create serious scheduling problems for all members of our team, as well as other patients.
If you are running late to your appointment please contact the practice to inform us of your new arrival time. If you are late 15 minutes or more, you will not be guaranteed the full amount of time for your appointment, and if you are 30 minutes late or more we may have to cancel your appointment and reschedule.
If you must change your appointment, we require a minimum of 48 hours' notice. If proper notice is not received, a cancellation fee of $75 will be charged to your account.
We enjoy caring for our patients and reserve your appointment time exclusively for you. We have adopted this policy for the benefit of our patients to eliminate extensive wait times that are a complaint in other office where appointments are double booked.
I have read and fully understand the scheduling and cancellation policy and agree to its terms and conditions.
Financial Options and Obligations
We offer a wide range of financial options in order to pay for your dental treatment.
We can receive payment towards your account from any insurance plan in which you can choose your own dentist (PPO,PDO,Premier,etc.). We do this as a courtesy to you, our patient. While we do our best to estimate your "out-of-pocket" expense based up on the information we receive from your plan, we are not resoonsible for any denial or reduction of payment as determined by your insurance. We can never guarantee payment from your insurance. Your insurance policy is a contract between you and your insurance company. The doctors are not part of the contract. Therefore, all charges incurred are your responsibility. This balance may include any deductibles, copayments, denials, and non-covered services. For balance owed, we require a credit card authorization.
- You are responsible for your charges: Patients or their legal guardian are responsible for all charges incurred during treatment and must pay for services. You may have insurance or financial support from your family or others, but you remain legally responsible for your bill.
- Payment is required at the time that the service is provided: If you are not covered by insurance, you must pay in full for all charges at the time of service unless prior arrangements have been made in our office.
- If you have insurance: As a courtesy service to you, we will determine your insurance benefits, estimate your out of pocket costs and file claims on your behalf. However, you must pay for estimate out of pocket expenses, including estimated co-payments, deductibles, non-covered services or services requiring further review by your insurance carrier before treatment is initiated. We will submit all necessary information for your insurance company to expedite payment of your claim and your rightful benefit.
FORMS OF PAYMENT ON BALANCE DUE
In order to facilitate access to the very best health care possible, you may choose from any of the following: Cash, Visa, MasterCard, AmericanExpress, Discover, MoneyOrder, Personal Checks, or CareCredit.
Several in-office payment arrangements are available for account balances. All fees will be disclosed to you and financial arrangements discussed and confirmed prior to treatment.
- Pay as You Go: You may choose to pay your obligation with cash, check or creditcard at the time of your visits
- Lending Point: With fast online approval, Lending point can help you get the healthy, radiant smile you've always wanted with the loan designed specifically for your dental needs. Lending point offers low monthly payment option, no up-front costs, and no prepayment penalties. Lending Point is a dental loan and can be subject to APR fees as set forth by Lending Point. Pre-approval is required. Go to www.lendingpoint.com for complete information and ask us in office about pre-approval information.
Please Read and Sign the Following:
- I understand that if I become delinquent on my account, my account will be turned over to a collection agency, and I will subsequently be reported to the credit bureaus. In case of total default, I promise to pay any collection costs and attorney fees incurred to collect on this account.
I certify that I have read, fully understand, and accept the above financial policy.