Optimum Dental 703-876-4700 7389 Lee Highway Suite 101 Falls Church, VA 22042
Patient Information
Patient Name
Date:
Last,
First
MI
(Preferred Name)
Name of Parents’ if Minor-________________________________Patient Gender: Male/Female (circle)
Marital Status: Mr./ Mrs./ Single/ Widowed/ (Please circle)
Patient Social Security #:
Patient Birth Date:
Phone Home:
Work:
(Responsible parent) Ext:
Cell: __________________E-mail Address_____________________________________
Address:
Street
Apartment #
City
State
Zip Code
Health Information
Date of Last Dental Visit: ______________________Reason for this visit:
Are you interested in any of these dental treatments? _______ Invisalign ________ Cosmetic Veneers ________Whitening
_____________
______ Sedation Dentistry
Have you ever had any of the following? Please check those that apply:
AIDS/ HIV
Alcohol Treatment
Anemia
Arthritis
Artificial
Joints/Skeletal
Implants, Valves
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Bloody
persistant
Dizziness
Drug Treatment
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Aches
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
Herpes
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Pacemaker
Pregnancy
Due date:_________
Radiation Treatment
Psychiatric Care
Respiratory Problems
Radiation Treatment
Rheumatic Fever
Rheumatism
Scarlet Fever
Shortness of Breath
Sinus Problems
Stomach Problems
Special Diet
Stroke
Tuberculosis
Tumors
Thyroid Problems
Tumors of Growths
Ulcers
Venereal Disease
Codeine Allergy
Penicillin Allergy
Sulfa Allergy
Anesthesia Allergies
Latex Allergies
Metal Allergies
Allergies Other
Weight Loss
(unexplained)
_________________

Have you ever had any complications following dental treatment?
Yes
No
If yes, please explain: _____________________________________________________________________________________

Have you been admitted to a hospital or needed emergency care during the past two years?
Yes
No
If yes, please explain:______________________________________________________________________________________
●
Are you now under the care of a physician?
Yes
No  Name of Physician: ____________________Phone: __________
If yes, please explain:______________________________________________________________________________________
● Are you currently taking any medications? If yes, please list: ____________________________________________
________________________________________________________________________________________

Do you have any health problems that need further clarification?
Yes
No
If yes, please explain: ______________________________________________________________________________________
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will
inform the doctors at the next appointment without fail.
________________________________________________________________ Date:
_____________
Signature- Patient, Parent, Guardian
Whom may we thank for referring you to our practice?
Dental Office
Yellow Pages
Newspaper
Name of person or office referring you to our practice:
Another patient, friend
School
Work
Another patient, relative
Other
Optimum Dental 703-876-4700 7389 Lee Highway Suite 101 Falls Church, VA 22042
Responsible Party Information
The following is for:
the patient’s spouse
the person responsible for payment
Name
Male
Female
Married
Single
Child
Other
Social Security# ___________________________ Birth Date-____________________
Home Phone-__________________________Work phone-____________________________Ext. _____________
Employer Name
Occupation:
Address:
Street
City,
State Zip Code
Street
Phone
Apartment #_________________________________
City
State
Zip Code
Insurance Information
Primary Insurance Information
Name of Insured:___________________________________________________________________ Is insured a patient?  YES
Patient’s relationship to insured: 
Insurance Plan Name and Address:
Self

NO
 Spouse Child  Other-____________
_____________________________________________________________________________
__________________________________________________________________________________________________________________________
Insured’s Birth-date Date: _________________ ID #: _____________________ Group #:
Insured’s Address:
Insured’s Employer Name:
Employer Address-___________________________________________________________________________________________________________
Secondary Insurance Information
Name of Insured:___________________________________________________________________ Is insured a patient?  YES
Patient’s relationship to insured: 
Insurance Plan Name and Address:
Self

NO
 Spouse Child  Other-____________
___________________________________________________________________________
__________________________________________________________________________________________________________________________
Insured’s Birth-date Date: _________________ ID #: _____________________ Group #:
Insured’s Address:
Insured’s Employer Name:
Employer Address-___________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Consent for ServicesAs a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their
care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial
arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the
patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance
companies and will credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance
company. A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are
satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at
the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to,
by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or
condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I understand that in the event my account becomes delinquent I agree to pay any and all collection, attorney’s and court costs necessary to clear this account balance.
I have read the above conditions of treatment and payment and agree to their content.
______________________________________________________________________ Date: _____________ Relationship to Patient: _____________________________
Signature of patient, parent or guardian/responsible party
This patient’s health history has been reviewed. Drs. Signature-_______________________________________ Date-______________________
Optimum Dental 703-876-4700 7389 Lee Highway Suite 101 Falls Church, VA 22042
Optimum dental
703-876-4700
7389 Lee Highway
Suite #101
Falls Church, VA 22042
Patient Name
Address
City, State, Zip
Dear PatientYou have scheduled an appointment on ____________________ at ______________________.
Welcome to our practice!
To introduce you to our practice and to facilitate your visit, we have enclosed some important information.
In order to gain a thorough understanding of your medical history we ask that you complete the enclosed “Patient
Information” and Privacy forms. Please arrive 10 minutes early for your appointment and bring your completed
paperwork along with your insurance information (insurance card or book) and a current set of x-rays.
At your first visit we will perform a thorough evaluation of your periodontal condition, a clinical examination:
including an oral cancer exam, any necessary x-rays and a prophylaxis (cleaning). This appointment will take
approximately an hour and a half. If you have to be pre-medicated (with an antibiotic), prior to your first visit,
please contact the office to discuss pre-medication requirements.
Our policy regarding x-rays-Simply put we require x-rays to diagnose your dental needs. If you have a current set
of x-rays (full mouth within the last three years and bitewing x-rays within the last year) please request them from
your previous dentist and have them sent to our office prior to your visit. If we do not receive these x-rays prior to
the visit or you do not bring them with you we will take new x-rays and you will be billed directly for them.
Our office is a family and cosmetic oriented practice so are happy to welcome patients at any age. We believe good
dental health starts very early so we usually see children starting at age 3. We are also pleased to offer a full range
of cosmetic dental services. Please feel free to speak with either the dental hygienist or me about whitening your
teeth, veneers or Invisalign braces. If you have a particular problem that you would like to address please do not
hesitate to ask us. That way we can discuss all of your options for improving your smile.
Last but not least, we would like to inform you that we do have a 48 hour cancellation policy in effect. If you are
not able to keep this scheduled appointment please contact our office immediately. Once again thank you for
selecting our office. We are looking forward to seeing you at your first visit.
Sincerely,
Chelsea L. Balderson, DDS
Optimum dental
7389 Lee Highway
Optimum Dental 703-876-4700 7389 Lee Highway Suite 101 Falls Church, VA 22042
Suite # 101
Falls church, va 22042
Acknowledgement of Receipt of Notice of Privacy Practices
Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to
document our good faith effort to obtain that acknowledgement.
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I,
Name}
, have {Please Print
received a copy of this office’s Notice of Privacy Practices.
{Signature}
{Date}
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)
Office, Dental Insurance Information and Financial Policies
Dear Patient:
Optimum Dental 703-876-4700 7389 Lee Highway Suite 101 Falls Church, VA 22042
Thank you for choosing our office for your dental needs. We would like to acquaint you with our policies regarding
dental insurance, schedule changes etc. We always strive to maintain quality dentistry with compassion in a
comfortable and friendly atmosphere. We hope that you and your family will feel welcome in our dental family.
Since we know it is not always possible to pay your dental bill in full, we would like to explain our financial options. Please choose the
option that works best for you.
 Dental Insurance-If you have dental insurance, as a courtesy to you, we will complete your insurance form with all the
necessary information and submit it to the insurance company. We ask that you pay the estimated co-payment at the time
services are rendered. If you fail to bring the required insurance information to your appointments we will ask that you pay the
bill in full and be reimbursed from your insurance company with paperwork provided by our office. Our office does not
guarantee that your insurance company will pay for the treatment you receive from our practice. If your claim is denied or the
treatment is down-coded and or alternative benefits given, you will be responsible for paying the full balance amount left on the
account at that time. ____________________( please initial)
Our office will not enter into a dispute with your insurance company over any claim, although we will provide the necessary
documentation your insurance company requests to settle the claim.
If your insurance company has not made a payment within 30 days of billing, the balance will become your responsibility.
(Insurance coverage is a contractual agreement between the insurance company and you or your employer. We have no control
over this relationship).
Payment is due at the time treatment is rendered. We accept Cash, Personal checks, most major charge or debit cards,
and Care Credit.
Monthly payments- If you need to make long-term payments we can offer financing with Care Credit. You must qualify to
use this option. Or we can offer a two-month payment plan with a credit card on file.
All patients with an outstanding balance will receive a statement each month. There is a finance charge of 1.5 % (18% APR) on
all accounts 60 days overdue. If you have a returned check you will be charged a return check fee of $50.00 per check.
We reserve the right to charge for appointments broken with out proper 48 hours notice. The length of the
appointment scheduled will determine a charge for the broken appointment. There is a minimum charge of $70.00 for
a broken appointment cancelled with less than 24 hours notice.
SIGNIFICANT EXPOSURE- Section 32.1-45,1(A) and (B), Code of Va. (1950, as amended) provides that in the event of
significant exposure (e.g. needle stick), consent for testing for Human Immunodeficiency Virus (HIV), Hepatitis B Virus and
Hepatitis virus is considered to have been given by the patient and /or healthcare worker thereby granting the Hospital the right
to perform such tests. Test results are confidential and can only be released in accordance with applicable laws and the policy of a
local hospital.
Minor Patients- The adult accompanying the minor is responsible for the payment on the account. For unaccompanied minors,
non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, a MC/VISA and or
check, cash payment is paid on the account at the time of service.
I authorize and release information and payment of my dental insurance to the dentist.
I have read and understand fully the financial options. I agree to accept responsibility for payment of my bill
including co-pays, deductibles or non-covered services requested by me. I understand that in the event my account
becomes delinquent I will be responsible for any collections, attorney fees at 33 1/3%, court costs, interest (and any
other charges incurred to collect this account) on the principal balance of 18% (eighteen) per annum from the date of
service. In the event the account is turned over to collections you will need to discuss all payment arrangements with
our attorney.
____________________________________________________
Signature of patient, parent or guardian
______________________
Date
rev. 9/15