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PATIENT INFORMATION

Excellence in Dentistry

PATIENT INFORMATION

Become a member of our dental family at Arrow Dental Center! Our doctors and their team work with patients of all ages in Monroe, LA and the surrounding areas. Many members of our staff have been with us for over 25 years, and we take pride in the family-like atmosphere our patients can enjoy at our office. Your smile and comfort are always our priorities. Excellence in dentistry—that’s what we strive for every day, and you will notice the difference as soon as you walk in our doors.

Proudly Serving Families in Northeast Louisiana & Southern Arkansas

Appointments

We are currently accepting new patients! To schedule an appointment, please call our office at (318) 361-0381. If for any reason you are unable to keep your scheduled appointment time, please call us with 48-hours notice to reschedule, so we can offer that time to another patient.

What to Bring to Your First Appointment

To save time in the office, please bring the following items with you to your first appointment:

  • Insurance Information/Card
  • Photo Identification
  • Any relevant medical records

Patient Forms

Filling out our patient forms before your first appointment will help you save time in the office during your visit. Please click the link below to download and print this paperwork.
Download Patient Form

Insurance

We accept most dental insurance plans. Please familiarize yourself with your insurance plan, paying close attention to your benefit maximums, deductibles and covered percentages. Our knowledgeable, experienced staff will help you completely understand your dental benefits and will prepare all the necessary forms for your benefits. However, we remind you that your specific policy is an agreement between you and your insurance company.

Please know that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. We do not render our services on the basis that insurance companies will pay all of our fees. We base our treatment on what is best for you. Your benefits are contracted between your employer and your insurance company.

Payment

Payment is expected at the time services are rendered, unless other arrangements have been made. This includes any copayments or deductibles (amount not covered by your insurance).

For your convenience, our office accepts cash, Visa, MasterCard, & Discover.

For more information about our office policies, or to schedule an appointment, contact us today at (318) 361-0381. Or, click here to make your appointment online!

Arrow Dental Center
Today's Date:

Patient's Name

First
MI
Last
Nickname

Address

Street
City
State
Zip

Phone Number

Primary
Mobile
Work
Date of Birth
Social Security Number
Drivers License #
State
Patient Employed By
Phone

Employer Address

Street
City
State
Zip
Sex
MaleFemale
Marital Status
MarriedSingleDivorcedSeparatedWidows

Emergency Contact Info

Name

Relationship to Patient
Primary Phone
Is the patient a minor?
YesNo
Full Time Student
YesNo
Name of school

Name of Responsible Party

First

Last
Date of Birth
Relationship to Patient
SpouseParentOther

Address (if different from patient)

Street
City
State
Zip

Phone Number (if different from above)

Primary
Mobile
Work

Employer (if different from above)

Phone

Employer Address

Street
City
State
Zip

Best Method to Contact You

Text MessageEmail
Best Number to Text You
Please Provide Your Email Address

Primary Dental Plan

Name
Phone
Address
City
State
Zip
Name of Insured
Date of Birth
ID #
Policy Number
Patient Relationship to Insured

Secondary Dental Plan

Name
Phone
Address
City
State
Zip
Name of Insured
Date of Birth
ID #
Policy Number
Patient Relationship to Insured

How did you hear about us?

FacebookPhonebookOur WebsiteOur LocationInternet SearchOne of our valued patientsOther

Other:
Patient Referred By:
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?
YesNo
If yes:
Have you ever been hospitalized or had a major operation?
YesNo
If yes:
Have you ever had a serious head or neck injury?
YesNo
If yes:
Do you take, or have taken, Phen-Fen or Redux?
YesNo
If yes:
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
YesNo
If yes:
Are you on a special diet?
YesNo
Do you use tobacco?
YesNo

Women: Are you...

Pregnant/trying to get pregnant? YesNo
Nursing? YesNo
Taking oral contraceptives? YesNo

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther
If other:
Do you use controlled substances?
YesNo
If yes:

Do you have, or have you had, any of the following?

AIDS/HIV Positive YesNo Alzheimer's Disease YesNo Anaphylaxis YesNo Anemia YesNo
Angina YesNo Arthritis/Gout YesNo Artifical Heart Valve YesNo Artificial Joint YesNo
Asthma YesNo Blood Disease YesNo Blood Transfusion YesNo Breathing Problems YesNo
Bruise Easily YesNo Cancer YesNo Chemotherapy YesNo Chest Pains YesNo
Cold Sores/Fever Blisters YesNo Congenital Heart Disorder YesNo Convulsions YesNo Cortisone Medicine YesNo
Diabetes YesNo Drug Addiction YesNo Easily Winded YesNo Emphysema YesNo
Epilepsy or Seizures YesNo Excessive Bleeding YesNo Excessive Thirst YesNo Fainting Spells/Dizziness YesNo
Frequent Cough YesNo Frequent Diarreha YesNo Frequent Headaches YesNo Genital Herpes YesNo
Glaucoma YesNo Hay Fever YesNo Heart Attack/Failure YesNo Heart Murmur YesNo
Heart Pacemaker YesNo Heart Trouble/Disease YesNo Hemophilia YesNo Hepatitis A YesNo
Hepatitis B or C YesNo Herpes YesNo High Blood Pressure YesNo High Cholesterol YesNo
Hives or Rash YesNo Hypoglycemia YesNo Irregular Heartbeat YesNo Kidney Problems YesNo
Leukemia YesNo Liver Disease YesNo Low Blood Pressure YesNo Lung Disease YesNo
Mitral Heart Prolapse YesNo Osteoporosis YesNo Pain in Jaw Joints YesNo Parathyroid Disease YesNo
Psychiatric Care YesNo Radiation Treatments YesNo Recent Weight Loss YesNo Renal Dialysis YesNo
Rheumatic Fever YesNo Rheumatism YesNo Scarlet Fever YesNo Shingles YesNo
Sickle Cell Disease YesNo Sinus Trouble YesNo Spina Bifida YesNo Stomach/Intestinal Disease YesNo
Stroke YesNo Swelling of Limbs YesNo Thyroid Disease YesNo Tonsilitis/td>

YesNo
Tuberculosis YesNo Tumors or Growths YesNo Ulcers YesNo Veneral Disease/td>

YesNo
Yellow Jaundice YesNo
Have you ever had any serious illness not listed? YesNo
If yes
Comments:

Dental History Form

What are your goals in coming to our practice today?
What is important to you in a dentist or dental practice?
Date of last radiographs (X-Rays) and exam:
Date of last hygiene continuing care appointment (cleaning or periodontal maintenance)
Former Dentist
Phone
If you left your previous dentist, what are the reasons?
Have you had any previous problems with prior dental treatment? YesNo
If yes, what were they?
Are you experiencing any pain now? YesNo
If yes, please describe
Have you ever been pre-medicated for dental treatment? YesNo
If yes, why?
Have you ever been anxious about having dental treatment? YesNo
If yes, would you be comfortable sharing why?
Would you like to discuss this concern with the doctor to learn about your relaxation options? YesNo

What concerns do you current have with your oral health or smile?

(please check all that apply

Jaw Joint PainClenching or Grinding of TeethDiscolored TeethCrowding/Crooked TeethMissing TeethSpaces in Between TeethLoose Tooth/TeethTooth Shape/SizeUnhappy With Appearance of TeethOverbiteUnderbiteUncomfortable BiteOld Fillings (gold or silver)Old CrownsSpeech ProblemsToo Much Gum Tissue When I SmileTooth Sensitivity to Hot/ColdTooth Sensitivity to BitingTooth Sensitivity to SweetsFood Gets Caught Between TeethDifficulty ChewingBad Breath

Other:

Have you ever had orthodontic treatment? YesNo
If yes, when?
Have you ever had periodontal treatment such as deep cleanings, root planning, or periodontal surgery?
YesNo
If yes, what kind of treatment and when?

Are you interested in learning about the following?

(please check all that apply)

Teeth WhiteningOrthodontic TreatmentTooth Replacement OptionsBotox For Clenching and GrindingTooth Colored FillingsDental ImplantsOral Hygiene Care for Infants/ToddlersCosmetic BotoxAt-Home Oral Hygiene CarePeriodontal Prevention/TreatmentJuvederm Filler Around Mouth

Other:

Acknowledgement of Receipt of Notice of Privacy Practices & Consent for use and Disclosure of Health Information

By signing this form you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

I understand that as part of my dental & healthcare, this facility originates and maintains health_records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility's Notice of Privacy Practices that provides a complete description of the uses and disclosures of my health information. I understand that:

  • I have the right to review this facility's Notice of Privacy Practices prior to signing this acknowledgement
  • This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address l've provided if requested.

Financial Policy

Our office is committed to providing you with the best possible care. lf you have dental insurance, we will help you receive your maximum allowable benefits. ln order to do this, we need your full understanding of our financial policy.

Payment for services is due at the time of service unless payment arrangements have been approved in advance. We do not offer in house financing. We accept cash, money orders, Care Credit, and all major credit cards. If you have insurance, we will ESTIMATE to the best of our ability your portion and we will file your insurance for you. Please be prepared to pay your portion at the time services are rendered. If your insurance company does not pay all that we have estimated, you will be responsible for any balance not paid by the insurance. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You MUST realize however that:

  1. Your insurance is a contract between you, your employer and the insurance company
  2. Dental insurance does NOT pay 100% of all treatment. It is meant to assist you in covering some of the expense and the remaining balance will be your responsibility.
  3. Please do not ask us to recommend treatment based on what your insurance will pay. We are committed to your dental health and will treat you according to your needs.

We must emphasize that as dental care providers, our relationship is with you and not your insurance company. Filing of all insurance claims is a service that we provide to our patients as a courtesy. All charges are your responsibility If you have any questions regarding this policy, please do not hesitate to ask.

Assignment & Release

I have read all the above information and I hereby authorize my insurance benefits to be paid directly to Dr. William C Johnston, D.D.S. I understand that I am responsible for the balance on the account regardless of my insurance. In the event that an attorney or collection agency is required to obtain a debt from you, our office will be entitled to recover any fees lost during this process.

PLEASE NOTE: We REQUIRE a 24-hour cancellation notice for alt appointments! A $25.00 fee will be enforced for all no-show and short notice cancellations!!

Patient's Name:
By entering your name, you agree to the above terms and conditions
Date:

Authorization to release medical/financial information to anyone other than yourself

Name:
Phone:
Relationship to you:
Name:
Phone:
Relationship to you:

ARROW DENTAL CENTER
1507 Lamy Ln Suite A
Monroe, LA 71201

Phone: (318) 361-0381
Fax: 318-388-4598
Johnstonwilliamc@yahoo.com

OFFICE HOURS
Mon: 8:00 AM – 6:00 PM
Tue: 8:00 AM – 6:00 PM
Wed: 7:00 AM – 5:00 PM
Thu: 7:00 AM – 5:00 PM
Fri: 8:00 AM – 5:00 PM
Sat: 8:00 AM – 5:00 PM
Sun: CLOSED