Curtis E. McRae, D.D.S.  

General Dentistry  

3601 Vista Way, Suite 205 Oceanside,

CA 92056  

 

   

Dear New Patient,  

 

Just a short note to tell you how much my staff and I are pleased that you have chosen us to help you with your dental needs. The part of our practice we like the most is the opportunity to serve nice people like you.  

 

All of us are dedicated to helping you achieve optimal dental health. On our website, you will find Patient Information Forms as well as our financial policies. We would request that you bring these with you to your appointment.  

 

We look forward to meeting you on your scheduled appointment date.  

 

With warm regards,  

 

Dr. McRae    

Curtis E. McRae, D.D.S.  CurtisE.McRae,D.D.S.hasbeenprovidingdentalcaretohispatientsintheNorthSanDiegoCountycommunityforover23years.Dr.McRaebeganhisdentalcareerasadentaltechnicianforfiveyearsaftergraduatingfromtheDentalTechnologyProgramatOrangeCoastCollege. 

Dr.McRaereceivedhisBachelorsDegreeinLiberalStudiesfromtheUniversityofCaliforniaatRiversideandhisDoctorateinDentalStudiesfromtheUniversityofSouthernCalifornia. 

CurrentlyDr.McRaemaintainsmembershipingoodstandingwiththe AmericanDentalAssociation,CaliforniaDentalAssociation,SanDiego CountryDentalSociety,NorthCountyImplantStudyGroup,California 

CenterforAdvancedDentalStudies,SanDiegoCerecStudyGroupandTrojanHorseStudyGroup 

Tostaycurrentwithourdentalhealthinformationandclinicaltechniques,heandhisstaffattendannualpost‐doctorateeducationalcoursestoprovidetheirpatientswiththebestoralhealthcarepossible. 

Dr.McRaeandhisfamilyhavelivedinthisareasince1989.HehasbeenanactivememberoftheRotaryClubsince1994andhasservedaspresidentoftheSanLuisReyRotaryClub. 

Dr.McRaeiscommittedtoahealthylifestyleandenjoyssurfing,skiing,golfing,wakeboardingandplayingtheguitar.Heisamemberofthealldentistband"Novocaine"thatplaysatvariousvenuesthroughoutSanDiego. 

Curtis E. McRae, D.D.S.   

TIME 9:20 AM Curtis E. McRae, D.D.S. DATE 7/1/2015 

MEDICAL HISTORY

PATIENT NAME _______________________________________________ Birth Date _____________________________________  

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the 

following questions. 

  Are you under a physician's care now? Yes No If yes, please explain: Have you ever been hospitalized or had a major operation? Yes No If yes, please explain: 

Have you ever had a serious head or neck injury? Yes No If yes, please explain: Are you taking any medications, pills, or drugs? Yes No If yes, please explain: 

Do you take, or have you taken, Phen-Fen or Redux? Yes No Have you ever taken Fosamax, Boniva, Actonel or any other

medications containing bisphosphonates? Yes No 

  Are you on a special diet? Yes No   Do you use tobacco? Yes No   Do you use controlled substances? Yes No 

Women: Are you   Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No 

Are you allergic to any of the following?   Aspirin Penicillin Codeine Local Anesthetics Acrylic 

  Other If yes, please explain: 

Do you have, or have you had, any of the following? AIDS/HIV Positive Yes No Cortisone Medicine Yes No Hemophilia Alzheimer's Disease Yes No Diabetes Yes No Hepatitis A Anaphylaxis Yes No Drug Addiction Yes No Hepatitis B or C Anemia Yes No Easily Winded Yes No Herpes Angina Yes No Emphysema Yes No High Blood Pressure Arthritis/Gout Yes No Epilepsy or Seizures Yes No High Cholesterol Artificial Heart Valve Yes No Excessive Bleeding Yes No Hives or Rash Artificial Joint Yes No Excessive Thirst Yes No Hypoglycemia Asthma Yes No Fainting Spells/Dizziness Yes No Irregular Heartbeat Blood Disease Yes No Frequent Cough Yes No Kidney Problems Blood Transfusion Yes No Frequent Diarrhea Yes No Leukemia Breathing Problem Yes No Frequent Headaches Yes No Liver Disease Bruise Easily Yes No Genital Herpes Yes No Low Blood Pressure Cancer Yes No Glaucoma Yes No Lung Disease Chemotherapy Yes No Hay Fever Yes No Mitral Valve Prolapse Chest Pains Yes No Heart Attack/Failure Yes No Osteoporosis Cold Sores/Fever Blisters Yes No Heart Murmur Yes No Pain in Jaw Joints 

Congenital Heart Disorder Yes No Heart Pacemaker Yes No Parathyroid Disease Convulsions Yes No Heart Trouble/Disease Yes No Psychiatric Care 

  Have you ever had any serious illness not listed above? Yes No If yes, please explain: 

Comments:   Nursing? Yes No 

  Metal Latex Sulfa drugs 

Yes No Radiation Treatments Yes No Yes No Recent Weight Loss Yes No Yes No Renal Dialysis Yes No Yes No Rheumatic Fever Yes No Yes No Rheumatism Yes No Yes No Scarlet Fever Yes No Yes No Shingles Yes No Yes No Sickle Cell Disease Yes No Yes No Sinus Trouble Yes No Yes No Spina Bifida Yes No Yes No Stomach/Intestinal Disease Yes No Yes No Stroke Yes No Yes No Swelling of Limbs Yes No Yes No Thyroid Disease Yes No Yes No Tonsillitis Yes No Yes No Tuberculosis Yes No Yes No Tumors or Growths Yes No   Ulcers Yes No Yes No   Venereal Disease Yes No Yes No Yellow Jaundice Yes No 

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. 

 

SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________ 

 

 

 

 

Financial Policy 

This statement is to inform you of our financial policy. We are committed to providing you with the highest quality dental care using only the best materials and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. Our financial policy is intended to facilitate service to you while minimizing our administrative costs. 

All charges that incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. If payment from your insurance company is not received within 60 days from date of service, you will be expected to pay the balance in full. 

As a courtesy to you, we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our office by signing the authorization on the Assignment of Benefits Agreement. In order for our office to file your insurance claim, you must bring a completed dental insurance form or proof of insurance to our office. 

Payment is due at the time of service provided. Our office accepts cash, personal checks, MasterCard, Visa, and Discover. Outside financing is available through CareCredit upon request and approval. 

Returned checks and balances older than 60 days must be subject to collection fees and finance charges at the rate of 1.83% per month. Additionally, our office may charge you for broken appointments and appointments cancelled without 48-hour advance notice. If you have any questions regarding our financial policy, please ask. We are committed to providing you with the most positive experience in dental care. 

_____________________________ Print Name 

_____________________________ ________________ Signature Date 

Curtis E. McRae, D.D.S.   

Assignment of Benefits Agreement 

Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by you insurance company. The following provisions identify our policies governing insurance claims.  

• Although we are willing to complete insurance forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate you financial obligation for your treatment.  

• We require you to sign this form and/or other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office.  

• It is your responsibility to pay the copayment, which is the amount not covered by your insurance company, at the time we provide service to you.  

• Insurance payments ordinarily are received within 30-60 days from the time billing. If your insurance company has not made payment to our office within 60 days, we ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time.  

• Our office does not guarantee that your insurance company will pay for treatment you receive from our office. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time.  

• Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with  regulations and the requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.  

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO CURTIS E. McRAE, D.D.S., INC. 

I AUTHORIZE CURTIS E. McRAE, D.D.S., INC. TO DEBIT MY CREDIT CARD IF PAYMENT FROM MY INSURANCE COMPANY HAS NOT BEEN RECEIVED WITHIN 60 DAYS OF RECEIVING TREATMENT.  

____________________ __________________ ____________ ___________  Print Name Credit Card Number Expiration V-code (3 digits on back) 

________________________ ______________ 

Signature of Patient/Responsible Party Date 

Curtis E. McRae, D.D.S.