Medical & Dental History Form

Medical & Dental History Form

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well-being.
Please indicate if you have experienced any of the following:
Please mark any of the following to indicate Yes in response to the question:
WOMEN ONLY: Are you:
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next detal appointment without fail.
Authorization
I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostics aids deemed appropiate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

TO MAKE AN APPOINTMENT:

CALL US AT 908-722-8110
EMAIL US AT CONTACT@BRANCHBURGDENTAL.COM
OR STOP IN AT 1069 US ROUTE 202 NORTH, BRANCHBURG NJ.

CONTACT US

IN OFFICE DENTAL MEMBERSHIP CLUB

Here at Branchburg Dental, it is our mission to deliver quality dental care to all of our patients, regardless of their insurance status. As dental health professionals, we are aware of the financial burden that proper dental care can place on a family.
We believe it is our responsibility to the community we serve to offer an affordable dental discount plan.

THE PLANS INCLUDES:

  • Two dental cleanings in a twelve-month period*
  • Two dental exams in a twelve-month period*
  • One emergency exam in a twelve-month period*
  • Annual Oral Cancer Screening
  • All necessary intraoral photographs*
  • All necessary periodontal measurements*
  • All necessary xrays- checkup and emergency appts*
  • One fluoride treatment (adult, 18+)*
  • Two fluoride treatments (child 17 and under)*
  • 15% savings on treatment (some exclusions apply)*

*Procedures above are patient specific based on patients’ needs and age.

*Inquire at office for specific exclusions

ADVANTAGES OF MEMBERSHIP:

  • No annual deductible
    • No annual maximums
    • No preauthorizations required
    • No waiting period or eligibility period for treatment
    • No missing tooth clause restrictions or exclusions for tooth replacement

TERMS AND LIMITATIONS OF PLAN:

  • This is an In-Office Patient Membership Club, not dental insurance. It cannot be combined with any other dental insurance or savings plan.
  • This membership is only accepted at Branchburg Dental located at 1069 Route 202 North, Branchburg, NJ.
  • This membership is non-transferrable. Family members cannot be substituted in for another family member.
  • This membership is non-refundable. No refunds will be given if a patient chooses not to take advantage of the benefits.
  • Rates are subjected to change annually.
  • Payments for restorative services are due in full at the time of services are rendered, unless other arrangements have been made prior to treatment.
  • Branchburg Dental LLC reserves the right to refuse treatment and/or terminate a patient’s participation in the membership with thirty days written notice if a patient’s account becomes delinquent or a patient is non-compliant.
  • This membership may be modified, amended, or canceled at any time with a written notice thirty days prior to cancellation. 
  • Membership participants are responsible for scheduling their periodic treatments. Services not utilized by the end of year membership period are not carried over to the following year.