Patient Information
Date of Birth: 
Spouse/Guardian Information
Date of Birth: 
Responsible Party
Primary Insurance
Date of Birth: 
Secondary Insurance
Date of Birth: 
Other Information
Date: 
MEDICAL HISTORY
Females
Are you taking birth control pills? YesNo
Are you pregnant? YesNo
Are you nursing? YesNo
Do you smoke or use tobacco? YesNo
Please check any of the conditions which may apply:
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Artificial Bones
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis
Congenital Heart Defect
Cosmetic Surgery
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hight Blood Pressure
HIV/AIDS
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Pneumocystitis
Psychiatric Problems
Radation Therapy
Rheumatic Fever
Seizures
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Allergies:
Asprin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Reason for today's visit: Exam Emergency Consultation
Are you in pain? YesNo
Please check any of the following problems that may apply:
  • Discomfort, clicking or popping jaw
  • Red, swollen or bleeding gums
  • Sensitive tooth, teeth or gums
  • Blisters/Sores in or around the mouth
  • Lost/Broken fillings
  • Teeth Grinding
  • Ringing in ears
  • Broken/Chipped tooth
  • Stained teeth
  • Locking jaw
  • Bad Breath
Do you require pre-medication? YesNo
Last dental exam:
Last dental x-rays:
Times a day you brush?:
Times a week you floss?:
How would you rate your smile?
*****What medications are you taking?
Nerve Pills
Muscle Relaxers
Pain Killers
Stimulants
Blood Thinners
Tranquilizers
Insulin
Meds for Osteoperosis
*****Have you ever taken:
  • Bisphosphonates (ex. Aredia/Fosamax)
  • Phen-fen/Redux
Date: 
FINANCIAL POLICY
Payment in full is expected when services are rendered. All other arrangements must be made prior to your appointment.
Insured Patients
  • Although your insurance may assist you with partial payment of your treatment, the estimated portion that is not covered, is due when services are rendered.
  • As a courtesy to our patients, we will file your primary insurance for you. If your insurance has not paid within 90 days, you will be responsible for the entire unpaid balance and payment in full will be expected at this time. We will however, continue to work with you and your insurance company to expedite your reimbursement.

We do not accept assignment of benefits for secondary insurance, however, we will provide a claim form for you so that you may file and be reimbursed by your company.

Payment may be made by any of the following methods. Please indicate your method of payment below:
Cash
Check
Credit Card
Information is available upon request for third party financing through the following:
CareCredit
  • I understand and agree that I am ultimately responsible for all fees incurred for my dental treatment regardless of payment or denial of my insurance claim(s) by my insurance company.
  • I agree to pay any and all unpaid balance on my account.
  • I authorize all insurance benefits paid directly to Drs. Hixon or Burger, or make payment immediately to Drs. Hixon or Burger.
  • If payment by the insurance company is made to the insured, I agree to endorse or have the insured endorse the benefits check to Drs. Hixon or Burger, or make payment immediately to Drs. Hixon or Burger.
  • I authorize the release of information to my insurance company, attorney or legal representative to obtain reimbursement of any claim(s) or for other reasons.
  • A finance charge of 1.5% will begin to accrue after 90 days from the date of service on the unpaid balance of my account even though insurance may be pending.
  • A fee of $30.00 will be incurred for each returned check.
  • I agree to pay collection costs, attorney's fees, court costs, and interest from the date of treatment if this account is assigned to collection status.
  • I have read, understand, and agree to the above terms.
  • I authorize this office to discuss my account with a spouse or parent/step parent (if patient is or is not a minor but using parent or step parent insurance).
Date: 
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICIES

I have received a copy of the Notice of Privacy Practices of Daniel A. Hixon, Jr., DDS and E. Brandon Burger, DDS. I hereby authorize, as indicated by my signature below, to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in Patient Consent Form.

Date: 
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