Find Us: 5831 Brooklyn Blvd. Brooklyn Center, MN 55429
teléfono español (612) 200-0863
(763) 533-8669
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Our Dentists
Dr Bill Kotonias
Dr. Lam Tu
Dr. Marty Spanish
Our Team
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Areas Serviced
Brooklyn Center, MN
Champlin
Osseo
Maple Grove
Crystal
Brooklyn Park
Columbia Heights
Fridley
Smile Solutions
Family Dentist
Gentle dentistry
Cosmetic Dentist
Dental Bonding
Enamel Shaping
Inlays/Onlays
Dental Implants
Tooth Colored Fillings
Laser Dentist
Porcelain Crowns
Teeth Whitening
Porcelain Veneers
Restorative Dentist
Tooth Colored Fillings
Root Canal Therapy
Tooth Extraction
Dental Bridges
Dental Crowns
General & Preventive Dentist
Dental Sealants
Fluoride Applications
Periodontal Therapy
Routine Cleanings
Cosmetic Dentures
Kids Dentist
Dental Exams And Cleaning Brooklyn MN
Join Our Team
Contact Us
Appointment Request
Dental Emergency
Menu
Patient Forms
Patient Forms
Transfer of Dental Records
Dentists & Team
Our Dentists
Dr Bill Kotonias
Dr. Lam Tu
Dr. Marty Spanish
Our Team
Office Information
Office Information
Refer-A-Friend
Office Hours
Reviews
No Insurance?
Dental Articles
Areas Serviced
Brooklyn Center, MN
Champlin
Osseo
Maple Grove
Crystal
Brooklyn Park
Columbia Heights
Fridley
Smile Solutions
Family Dentist
Gentle dentistry
Cosmetic Dentist
Dental Bonding
Enamel Shaping
Inlays/Onlays
Dental Implants
Tooth Colored Fillings
Laser Dentist
Porcelain Crowns
Teeth Whitening
Porcelain Veneers
Restorative Dentist
Tooth Colored Fillings
Root Canal Therapy
Tooth Extraction
Dental Bridges
Dental Crowns
General & Preventive Dentist
Dental Sealants
Fluoride Applications
Periodontal Therapy
Routine Cleanings
Cosmetic Dentures
Kids Dentist
Dental Exams And Cleaning Brooklyn MN
Join Our Team
Contact Us
Appointment Request
Dental Emergency
Intake Form
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Intake Form
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How Did You Hear About Us?
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Do you have, or have you had, any of the following?
*
Abnormal Cholesterol
ADHD
Afib
Allergy - Anesthetic
Allergy - Medication
Allergy - Other
Alzheimer's
Anemia
Arthritis
Artif. Heart Valve
Artificial Joints
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Have you ever had any serious illness not listed above?
*
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No
If yes, please describe or name the illness
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Comments
FINANCIAL POLICY
Welcome to Brooklyn Blvd Dental! Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining important health treatment. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we are providing the payment options listed below:
Mode of Payment
*
Payment in Full (without insurance):
•
Cash or Check -
A bookkeeping courtesy of 5% is given for payment in full at the time of treatment.
•
Credit Card -
We accept Visa, MasterCard, and Discover. (5% courtesy does not apply.)
With Insurance:
Your out-of-pocket co-pay is due at the time of treatment. After your insurance claim has been processed, any remaining balance is due in full at that time.
Extended Payment Plan:
•
Dental Fee Plans -
We offer the Care Credit payment plan to qualifying candidates with interest-free financing for up to18 months. Please see our Office Manager for an application.
(Good credit standing required.)
Subscribers
Name
Date of Birth
MM slash DD slash YYYY
Social Security #
Phone
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance
Name
Group #
ID #
Employer
Name
* For dental work over $200.00. a current credit card number and expiration date is required. We will not carry an account balance past 90 days.
As a courtesy to our patients, all insurance forms wlll be filed on behalf of the patient by our office, free of charge.
Please be advised that regardless of your dental coverage, our Clinic relies on you for settling your account.
We have eliminated costly bookkeeping and billing fees by implementing the above policy. The savings is reflected in our fee schedule, thus maintaining reasonable fees for our patients.
Broken Appointment Policy:
There will be a $50 per appointment hour chair charge for failed appointments or appointments cancelled with a less than 24-hour notification.
COVID-19 SCREENING FORM
By signing this form I consent to the following:
1. I have not had or have been diagnosed with COVI D-19 in the last 14 days.
2. I do not have any of the following symptoms linked to COVID-19 listed below:
Fever
Fatigue
Loss of taste/smell
Blueish lips/face
Muscle pain
Dry Cough
Trouble Breathing
Shortness of Breath
Chills
Headache/sore throat
3. I have not been in contact with anyone sick and/or confirmed to be positive with COVID-19.
4. I have not traveled to any regions affected by COVID-19 in the past 14 days.
Consent
*
I knowing and willingly consent to treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I confirm all of my questions were answered truthfully and to my satisfaction. This form has no expiration date.
*
HIPAA Acknowledgement
I understand that I have certain rights to privacy regarding my protected health information.
These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Obtaining payment from third party payers (e.g., my insurance company);
I have also been informed of, and given the right to review and secure a copy of your Notices of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA.
I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.