(727) 78-SMILE • (727) 787-6453 •

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Thank you for choosing our dental practice. We look forward to meeting you, and giving you the care and attention that will continue to earn your trust.

We take pride in out office, staff, and most of all, out patients. We strive for excellence by listening to your individual goals and providing the treatment to meet your every expectation.

Here, you are more than a patient, You’re Family.

Look forward to seeing you.

lindsaysig

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Understanding Your Dental Benefits

We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of your Dental Benefits that we require you read and sign prior to treatment.

We Gladly File Your Insurance

Your insurance policy is a contract betw,een you and your insurance company. It is important to know that professional services are rendered and charged to you, the patient.

It is our responsibility to provide the utmost quality care. Diagnosis and treatment are determined by your Doctor, not your Insurance Company. Our obligation is to help you as much as we can by completing all forms pertaining to your claim and submitting them promptly to your company. This helps you obtain the reimbursement you are entitled to receive as quickly as possible.

Because different Insurance Companies reimburse the office at their own “Usual and Customary Fee” rates (which may be lower than ours), there will be an In-Office Co-Pay for each visit of treatment to you, the patient. Should your total treatment be covered under your plan, our office will reimburse you, or add the credit to your account after the Insurance Coverage has been received.

As your doctor may be a “Provider” on your Particular Plan, this does not mean that each visit is covered at 100%. Not all dental services may be covered under your particular plan (ie Crowns, Gum Disease Treatment, and/or White Fillings). You may be obligated to pay the additional fee that your Insurance does not cover. At your request, we are willing to send a Pre­-Determination to your Insurance Company before treatment so you have a greater understanding ofyour financial responsibilities.

Please Research your Insurance Company before your visit with us, so that we are able to serve you and answer any questions you may have. If there is a question about your Insurance Payment, or non-payment, we will be happy to assist you as much as we can, but the question and answers also should be directed to your particular Insurance Company. The more information the company receives, the greater chance the industry will change.

Thank You for understanding our Benefit Options. Please let our receptionist know if you have any questions or concerns.

I have read, understand, and agree to the provisions of these Benefit Options. In the event of defaults in the payment of arrangements made, and if these arrangements are placed in the hands of an attorney at law for collection, the undersigned hereby agrees to pay all costs of collection including a reasonable attorney’s fee. Presentment protest and notice are hereby waived.

New Patient Form2

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure if your protected health information to carry out treatment, payment activities, and healthcare operations.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of treatment, payment, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice Accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in out Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will include the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notices of Privacy Practices, including any revisions of our Notices, at any time by contacting:

Expressions Cosmetic & Family Dentistry
Dr. Lyndsay H. McCaslin
4852 Ridgemoor Blvd, Palm Harbor, FL 34685
Phone: 727-787-6453
Email: Expressionsdentistry@yahoo.com

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue to treat you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

If a personal representative on behalf of the patient signs this consent, complete the following:

** YOU ARE ENTITLED TO A COPY OF THIS FORM AFTER YOU SIGN IT**

Patient History and Information

Please answer the following questions.

Dental History

Teeth Appearance

Medical History

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.


Women: Are you:

Allergies - Check all that apply

Pre-existing Conditions

Acknowledgement and Authority

I consent to treatment as necessary or desirable to the care of the patient first named above. Including, but not limited to whatever drugs, medicine, performance of operations and conduct of laboratory, x-ray, or other studies that may be used by the attending doctor, or his nurse of qualified designate. I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, AT THE TIME OF SERVICE, unless other arrangements are made with the Financial Department. In the event of Default, the undersigned applicant agrees to pay interest at the rate of 1 1/2 % per month on any outstanding balance (18% Annual Interest). In addition, the undersigned applicant agrees to pay all court costs and attorney's fees reasonably necessary for collections, including attorney fees on appeal.

Your Financial Options

Thank You for selecting us as your dental health care provider

We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of your financial options that we require you to read and sign prior to treatment
  • Full payment is due at the time of service unless other arrangements have been made. We graciously accept Cash, Checks, Visa, MasterCard, Discover and American Express
  • For Patients with comprehensive treatment plans, we offer a definitive payment plan for 3 months with no interest
  • We offer extended payment plans with prior credit approval by outside lending organizations such as:
    • Fifth Third: 12 months interest free; with no processing fee.
    • Care Credit: 12-18 months interest free, with a processing fee that will be calculated to 7% your total comprehensive treatment plan.
We gladly file your insurance

Your insurance policy is a contract between you and your insurance company. It is important to know that professional services are rendered and charged to you, the patient. Because different insurance companies reimburse the office at their own “Usual and Customary Fee” rates, there will be an In-Office co-pay for each visit of treatment to you, the patient. Should your total treatment be covered under your plan, our office will reimburse you, or add a credit to your account after the Insurance Coverage has been received.

Not all dental services may be covered under your particular plan. Diagnosis and treatment are determined by your doctor, not your insurance company. Our obligation is to help you as much as we can by completing all forms pertaining to your claim and submitting them promptly to your company. This helps you obtain the reimbursement you are entitled to receive as quickly as possible.


Minor Patients
The parent or guardian accompanying a minor is responsible for the full payment regardless of any insurance coverage through a divorced parent situation. For unaccompanied minors, non- emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa, MasterCard, Discover, or payment by Cash or Check at the time of service.

Thank you for understanding our financial options. Please let our receptionist know if you have any questions or concerns.

I have read, understand, and agree to the provisions of these Benefit Options. In the event of defaults in the payment of arrangements made, and if these arrangements are placed in the hands of an attorney at law for collection, the undersigned hereby agrees to pay all costs of collection including a reasonable attorney’s fee. Presentment protest and notice are hereby waived.

Keeping your Scheduled Appointments are Very Important at our Office

Unless cancelled at least 24 hours in advance WEEKDAY, and at least 48 hours in advance for SATURDAY there will be a fee for missed appointments at the rate of a $50 per hour of time. Please help us serve you better by keeping all scheduled appointments. Keeping your Scheduled Appointments are Very Important at our Office … Unless cancelled at least 24 hours in advance WEEKDAY, and at least 48 hours in advance for SATURDAY there will be a fee for missed appointments at the rate of a $50 per hour of time. Please help us serve you better by keeping all scheduled appointments.

VELscope Agreement

Did you know that one America dies from Oral Cancer every hour?

In 2013, Dr. McCaslin's mother, Becky, was one of these victims - and we want to prevent this tragedy for you and your family.

Tobacco, Alcohol, and the HPV virus are considered major pre-disposing risk factors to Oral Cancer, but more than 25% of oral cancer victims have no such lifestyle risk factos. For this reason, we believe that all individuals over the age of 18 should have an annual Comprehensive Oral Exam.

At our office, we have incorporated the VELscope Oral Cancer Screening System. This 3 minute exam has been cleared by the FDA and is used to assist Dr. McCaslin, and her hygienists in detection cancerous and pre-cancerous growths that may not appear to the naked eye.

This screening is completely pain free, and is affordably priced. At approximately $19 (which may or may not be covered by insurance), isn't it worth the peace of mind?

YES! I would prefer to have the VELscope Oral Screening at this time.

No... I would prefer NOT to have the VELscope Oral Screening at this time.

Sending
Chelsea Hardesty, CDA

ChelseaHardestyIn 2012, Chelsea graduated from the Certified Dental Assistant Expanded Duties program at the Ultimate Medical Academy in Clearwater, FL.  She enjoys making people happy through fixing their smiles.  Chelsea loves spending time with her family, boating, and beaching in the Florida sunshine.

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Chelsea White, CDA

ChelseaWhiteChelsea is a 2012 Dental Assistant graduate with Expanded Functions from Central Florida Institute.  Chelsea enjoys patient interactions, and making smiles better and brighter.  She has 2 cats and enjoys beaching and reading. 

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Kara Brackman RDH, BS

KaraBrackmanKara is a certified registered dental hygienist.  Graduating from St. Pete College in 2013, she continued her education and completed her Bachelor’s degree in 2015 in Dental Hygiene.  She enjoys dentistry because it is always changing and evolving.  She helps our patients achieve optimal oral/overall health through preventative and gum tissue care.  In her free time, she enjoys the beach and spending time with her friends and family.

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Anjuli Avis, RDH

person-placeholder-femaleAnjuli is originally from Chicago, and graduated in 2007 with her associates in Dental Hygiene from Hillsborough Community College.  Continuing Education is a passion for Anjuli, and her appreciation for dentistry comes through the fact that it allows her to be a clinician and a lifelong student with the ever-changing technologies in medicine.  She enjoys the culinary arts, fitness, cars, trivia, and travelling with her husband.

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Kristy Klibanoff, RDH

kristykibanoffKristy is a 2013 graduate of St Pete College’s Registered Dental Hygienist Program.  As she was born and raised in Palm Harbor, she loves the area, work, and spending time with her family and friends.  Kristy calms the nerves of anxious patients and enjoys educating for a healthier smile.  

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Shannon Webster, CDA

ShannonWebsterBorn and raised in Florida, Shannon loves the sunshine, traveling, and spending time with her husband and 3 dogs.  She has been in dentistry for over 10 years, and enjoys helping patients attain optimum health through scheduling planned treatment.

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Adrianne Marzo, CDA

AdrianneMarzoAdrianne has been in dentistry for over 10 years, and loves meeting new people.  She helps our patients attain their dental health goals.  Originally from Up State New York, Adrianne loves time spend with her family, reading, cleaning and traveling.

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Shannon Lertola, CDA

Shannon

As Certified Dental Assistant, Shannon has had further education in TMJ Dysfunction.  She enjoys helping patients understand how and why dental care is deemed necessary.  Shannon likes nature walks, reading, and spending time with family and friends.

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