Existing Patient Check-in Form

Make a Virtual Appointment

Community Outreach

2715 Pennsylvania Ave. SE

Washington, D.C. 20020

202-575-0152

Existing Patient Online Patient Check-in

Patient Information

Existing Patient Online Patient Check-inName: Enter Text

Email: Enter Text

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Form received.

Insurance Company: Enter Text

Home or Cell Phone: Enter Text

Insurance Member ID: Enter Text

Date of Birth: Enter Text

Home Address: Enter Text

City: Enter Text

State: Enter Text

Zip code: Enter Text

Social Security Number: Enter Text

Do you presently have or previously had any medical conditions such as High Blood Pressure, Diabetes, Stroke or any other medical condition?

Yes - If Yes, please list below.

Please list ALL Present or Previous Medical Conditons. Enter Text

Do you presently have or previously had any Dental Procedures such as crowns, extractions, deep cleaning, or any other dental procedure?

Yes - If Yes, please list below.

Dental History: Enter Text

Are you a smoker?

Yes

Name of Current Physician: (If None, Write N/A) Enter Text

Phone Number of Current Physician:( If None, Write N/A) Enter Text

Address of Current Physician: (If None, Write N/A) Enter Text

Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?

Yes

Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?

Yes

Do you presently have or previously had the coronavirus (COVID-19)?

Yes

By checking this box, I understand the above information and agree with its contents, agree to allow Stellar Smiles Dental Care / Dr. Carlos Jones, DDS to bill my insurance and consent to typing my name below as my Electronic Signature.

Typing Your Full Name in the Feild Below Satisfies the Signature Requirement: Enter Text

Date: Enter Text

Reason For Virtural Visit: Enter Your Message

Do you have any allergies?

Yes - If Yes, please list allergies.

Enter Text

Treatment Plan / Date- 1-2 business days of Form Date /Provider- Dr. Carlos Jones /

Service- D0140 Limited Eval (VIA PHONE/COVID-19) /Fee- Varies/Insurance Coverage-Estimated 100% Guarantor Responsibility-Estimated 0%

Insurance coverage is only an estimation. Guarantor is responsible for all treatment not covered by insurance. By checking the box below, I request and authorize Dr. Carlos Jones, DDS or qualified assignee to perform the work described above via phone (Teledentistry) due to the COVID-19 Pandemic.

By checking this box, I understand the above information and agree with its contents and agree to allow Stellar Smiles Dental Care / Dr. Carlos Jones, DDS to bill my insurance.

Insurance Information

Dental / Medical History Information

General Consent / HIPAA

Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. We are allowed to release this information to your insurance company or as necessary to get paid for our services. You can have access to your records by simply asking.

By agreeing with this consent form, you permit the release of any information to or from your dental practitioner as may be required.

You certify that you, and/or your dependent(s), have insurance coverage as submitted on the following registration form and assign directly to your dental practitioner all insurance benefits, if any, otherwise payable to you for services rendered. You understand that you are financially responsible for all charges whether or not paid by insurance. You authorize the use of your signature on all insurance submissions. Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services.

I give consent for myself/my child to receive dental treatment deemed necessary by the providers at Stellar Smiles Dental Care. I also understand and consent to the following: During the course of treatment, I may undergo procedures in all phases of dentistry, including periodontics (gum treatment and surgery), oral surgery (extractions), endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, restorative dentistry, sleep apnea treatment, oral pathology, pediatric dentistry, radiography and the use of local anesthetics. I understand that the use of local anesthetics carries a small risk for swelling, bruising, allergic reaction, changes in pain perception, or prolonged anesthesia. This consent shall be considered in effect until rescinded or revoked. I consent to Oral / Facial Photographic Images required when dental radiographs do not adequately indicate the necessity for the requested treatment using a digital camera or intraoral camera. An intraoral camera allows our practice to view clear, precise images of your teeth and gums. These images allow us to make a more accurate diagnosis and develop a better treatment plan for each patient.

No guarantees can be made about treatment outcomes, restorations longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.

I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child’s) health care, advice, and treatment to another dentist, or for evaluating and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to dentist or dental group and understand that my insurance benefits may pay less than the actual bill for services and that I am responsible for any services not paid or covered by my insurance benefits and any account balance.

I consent to Oral / Facial Photographic Images required when dental radiographs do not adequately indicate the necessity for the requested treatment using a digital camera or intraoral camera. An intraoral camera allows our practice to view clear, precise images of your teeth and gums. These images allow us to make a more accurate diagnosis and develop a better treatment plan for each patient.

Teledentistry Consent & Notice

"Telehealth" is the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth includes synchronous interactions and asynchronous store-and-forward transfers. "Asynchronous store and forward" means the transmission of a patient's information from an originating site to the health care provider at a distant site without the presence of the patient.

I attest to the accuracy of the information on this form.

Chief Complaint

Treatment Plan

Stellar Smiles Dental Care Treatment Plan

Date Provider Service Fee Insurance Coverage Guarantor Responsibility

1-2 business days of Form Date Dr. Carlos Jones D0140 Limited Eval (VIA PHONE/COVID-19) Varies Estimated 100% Estimated 0%

2715 Pennsylvania Ave. SE

Washington, D.C.

20020

202-575-0152