Step 1 Title

Step 1

Patient Information

Check Appropriate Box

Responsible party Information

How would you like to pay for your portion of the provided services?

Responsible party's Spouse

Dental Insurance Information

Secondary Dental Insurance Information

Step 2 Title

Step 2

Patient Medical History


General Health

Are you currently on any prescription or over the counter medications, vitamins, nurtritional or Herbal supplements?

Are you allergic to any medications?



Please mark the one that applies to you and your medical History.







Please mark yes or no individually for each questions
High or low blood pressure Heart Disease Osteoporosis
Heart Attack Cardiac Pace Maker Chest Pains
Rheumatic Fever Heart Murmur Long-Term Steroid Treatment
Swollen Ankles Artificial Heart valves Scarlet Fever
Fainting/seizures Frequently Tired Tuberculosis
Asthma Anemia Glaucoma
Epilepsy/ Convulsions Emphysema Liver Diseases
Leukemia Cancer Hemophilia
Diabetes Arthritis/ Rheumatism Respiratory problems
Kidney Disease Jaundice/Hepatitis Mitral valve prolapse
AIDS/HIV Infection Sexually Transmitted Disease Eating Disorders
Thyroid Problem Stomach Troubles /Ulcers Neck or Back Problems

Do you have any other medical or health condition which is not listed?

Step 3 Title

Emergency Contact


Dental History



Have you ever had a serious problem associated with a previous dental treatment?

what dental aids do you use?

Please answer yes or no

Are you hesitant to come to the Dentist?


Do you snore or have trouble sleeping?


Do your gums bleed during brushing or flossing?


Would you like to have a whither or brighter smile?


Do you have a bad taste or odor in your mouth?


Would you like to have a straighter teeth?


Does food frequently get caught between your teeth?


Do you have missing teeth that you want replaced?


Do you have dental fillings that you don't like?


Do you have loose dentures or partials?


Do you believe in the benefits of fluoride?


Consent for Treatment

I certify that I have read and understand the above informations to the best of my knowledge. The above questions have been accuratly answered. I understand that providing the incorrect information can be dangerous to my health. I hereby authorize YOUR EXPRESSIONS to administer and perform the neccessary procedure, such as X-rays, anesthetics and dental treatment deemed necessary or advisable with the diagnosis of my dental condition. I undertand there are certain risks inherent in dental treatment; such as but not limited to: pulpal sensitivity or damage, Tissue swelling or bruising, soreness of jaws, paresthesia and other procedure specific risks.

Children or Minors

Because(Name of the child) is a minor, it is necessary that signed permission be obtained from a parent or guardian before any dental services are rendered, such authorization is hereby granted. futuremore, I agree to be responsible for any bills incurred on behalf of this child during their dental treatment.

Step 4 Title

Office Policy

Financial Policy

Thank you for choosing Your Expressions to serve your dental care needs. We provide high-quality dental care to our patients and are committed to your treatment being successful. Please understand that your financial obligation is considered a part of your treatment. In the interest of good dental care practice it is desirable to establish a credit policy to avoid misunderstanding. To assist our patients, We offer the following methods for taking care of their account in our office.

On your first visit we expect you to supply our office with your insurance information and photo ID card. If any changes should occur during the time you are a patient it is your responsibility to inform our office with any changes. Our office will not be responsible for claims submitted to insurance companies by which you are no longer covered.

New patients are required to pay for services in full on their first visit. If the patient is a member of an HMO/DMO plan then the co-payment is due. Patients are required to pay their deductible and co-payments at the time of each vist.

While we accept most insurance plans, and are happy to aid in submissions of your claims, it is your reponsibility to read your policy and be aware of services covered or not covered by your individual plan.

As a courtesy, we will gladly bill your insurance when you provide us with the current information and any necessary forms. Often times we are able to contact your insurance provider prior to your appointment, and estimate your portion of the bill. We ask that you either pay your portion of the bill at the time of service, or that a suitable written financial agreement be reached at the time of service. Even though you may have an insurance claim pending. You will receive a monthly statement for the outstanding balance on your account until it is paid in full, We cannot accept responsibility for collecting an insurance claim after 60 days or for negotiating a disputed claim. Insurance policies are a contract between you, your employer and the insurance carrier. Please be aware that some, and perhaps all of the services rendered may not be covered under your individual insurance policy. You are ultimately responsible for payment of your account.

If no payment is received on an account after two monthly statements our office will make every effort to contact the responsible party. If the party responsible cannot be reached, a third bill will be sent indicating that “This will be the final notice for payment. If the party fails to contact our office after receiving such notice, the account will be sent to a collection agency. Responsible party shall then be subject to collection agency charges.

Financial options are available to all patients. Please feel free to ask one of our office personnel.

Failed or Cancelled Appointments

If an appointment has been reserved for you, we kindly ask that patients give us twenty-four hour notice for cancellations; otherwise, we reserve the right to charge a minimum of $45 per hour which is currently our broken appointment fee. If the appointment is with a specialist, the minimum fee is $50.00 per half hour visits. The length of time reserved and the number of prior failed appointments determines your charge, We will not offer appointments to patients who fail multiple appointments without having given us proper notice.

Estimates and Fees

After x-rays and examination, you are entitled to and should ask for an estimate of fees to cover your treatment, All estimates are based upon conditions viewed at the time of diagnosis, unforeseen circumstances, such as pulpal therapy or cracked teeth could alter an estimated fee, It is customary to pay for dental Services when they are rendered. There is a service charge on all unpaid accounts.

Delinquent Accounts

Delinquent accounts will have to be turned over to a Credit Reporting Collection Agency.

Notice of Privacy Practices (HIPAA)

A laminated copy of our office Notice of Privacy Practices (HIPAA) is avaliable in our office. 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 our treatment, payment activities 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. We encourage you to read it carefully and completely before signing this Consent. Upon your request we will be happy to provide you with your own personal copy of our Privacy Practices.

Step 5 Title

YOUR EXPRESSIONS FAMILY DENTISTRY

Dr Pallavi Chellur
2864 route 27, suite B
North Brunswick, NJ-08902
732-297-6111/6112

Authorized Signature on file
Release of information/Financial Responsibility/ Authorization for payment

I (name of the patient) and / or (name of insured) hereby authorize Your Expressions to affix my name to any and all claims or documents as related to any and all health benefits due me and my dependents through my employment with(name of employer). I hereby authorize payment of dental benefits otherwise payable to me directly to the office above. I have reviewed the payment plan and fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefits plan, Unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted under applicable law, I authorize release of any information related to the claim.

This "Authorization" will be valid from this date and shall expire in one year.
Expiration Date:

Step 6 Title

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have come to our office today for a routine dental evaluation and/or treatment that wil be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge,have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself,please be truthful and candid in your answers.

HAVE YOU BEEN DIAGNOSED POSITIVE FOR THE COVID-19 VIRUS AT ANY TIME?


ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?


DO YOU HAVE A FEVER?


DO YOU HAVE ANY SHORTNESS OF BREATH?


DO YOU HAVE A DRY COUGH?


DO YOU HAVE A RUNNY NOSE?


DO YOU HAVE A SORE THROAT?


DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?


HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?


HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?


WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?


WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?