- 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)
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. After your dental insurance as paid for dental services rendered, you may have an outstanding balance. This balance may include any deductibles, copayments, denials, and non-covered services. For balance owed, we require a credit card authorization.
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
- Prepayment in Full: A Prepayment Courtesy will be given for payment in full before or at the first treatment visit (does not include CareCredit payment)
- Split Payment: One half or one third of the total treatment is due at the preparation visit; the second and third payments due in the middle of treatment; and final paymentat the cementation visit of the dental appliance.
- CareCredit: With fast online approval CareCredit can help you get the healthy, radiant smile you've always wanted with the card designed specifically for your dental needs. CareCredit offers No Interest and low monthly payment options, no up-front costs, no prepayment penalties, and no annual fees. CareCredit is a medical/dental line of credit, and can be subject to interest fees as set forth by CareCredit. Pre-approval is required. Go to www.carecredit.com for complete information and pre-approval.
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.