DENTIST MANCHESTER CT--Carol Skerpan-COMPLETE DENTISTRY STUDIO

Complete Dentistry

                 studio

  Carol Lee Skerpan, D.M.D.             253 East Center Street    Manchester, Connecticut
06040

It would be a privilege to welcome you into our special family of patients!

PHONE MAP

860-649-4435

  Flexible-Hours--Monday thru' Saturday
on-site parking and on the bus-line

  Please be patient with the answering-service--
Leave two telephone numbers and best times to reach you.
    Thank you!

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FOR WRITTEN-DIRECTIONS:
READ FIRST below---THEN click @ right:
. At Google-maps---
. Fill-in blue-box with starting point & destination
. Click lower white-box of choice

WRITTEN DIRECTIONS

Contact Form-New Patient Form

* Indicates required field

Name *

First

Last

First Contact Phone Number--- *

Second Contact Phone Number---(e.g., work, landline, friend, other) *

WHO Referred you to this Office?--or HOW did you Find out about Us? *

Enter Best Day & Time to Reach YOU *

Please enter anything else we should know upon calling you: *

By Clicking To Submit I have understood and agreed that the above information will be forwarded to this office by email and not a secure messaging system. This form should
not be used to transmit private health information. This office disclaims all warranties with respect to the privacy and confidentiality of any information submitted through this form.

CLICK TO SUBMIT

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A WELCOME

DR SKERPAN-SERVICES-VIDEO

TOOTHSOME TALK---BLOG

w e b site by--c l s k e r p a n

© Copyright 2020. All Rights Reserved by Carol Lee Skerpan, DMD
© Images in this website are protected by copyright & may not be downloaded,
republished, retransmitted, reproduced or otherwise used as a stand-alone file.

COVID-19 Times
'Welcome Back Letter' for Our Patients
What Should You Expect at Our Dental Office?

COVID-19 Times
Pre-Appointment Compliance Steps
'Pre-Appointment Update Form'

Within 24 hours of your visit the office will call you for a pre-appointment screening & any update of scheduled time.
The 'Pre-Appointment Update Form' below must be SUBMITTED BEFORE the pre-appointment call.
The benefit information in the form below must be completed for benefit submission. The Benefit-Card must also be presented at the office.

Preparing an appointment setup now is more labor intensive and requires allotting more time for you. Therefore, let the office know more than 72 HOURS before the appointment if you think you will need to change it---NOT ON the day of the pre-appointment screening call and NOT AT the pre-appointment screening call!
If you are not feeling well it is expected that you reschedule your appointment. If you have a cough, fever or flu-like symptoms you will not be allowed in the office and you will be rescheduled.
Please arrive on time and alone in the office for your appointment. We ask that anyone with you remain outside.
Please limit personal items to a minimum or leave them in the car.
Patients are to clean & brush their teeth prior to their arrival.
We ask that you use the bathroom as little as possible, and there will be no tooth-brushing allowed in the bathroom!
We ask that you bring your mask to the office--and wear it throughout the office except when in the treatment chair!

ALL changes have been made to protect ALL involved--to keep ALL patients, the office & doctor as safe as possible!
It is expected that everyone will responsibly comply and follow these protocols.
Non-compliant and dis-respectful behavior will not be tolerated, risking discontinuation of the visit.

----------------------------------------------------------------------------------------------------------------------

'Pre-Appointment Update Form'

   The appointment will be rescheduled if this form
is NOT received in the office MORE THAN 24 hours BEFORE
the scheduled appointment time.
It must be received FULLY completed--properly & accurately.  ****

* Indicates required field

NAME *

First

Last

EMAIL *

1st PHONE NUMBER: *

2nd PHONE NUMBER--A DIFFERENT ONE FROM THE 1st PLEASE *

LIST ALL MEDICATIONS (PRESCRIPTION AND OVER-the-COUNTER)--IF you are taking NO MEDICATIONS, enter N/A in the box below: *

ADDITIONAL SPACE FOR LISTING MEDICATIONS: *

DENTAL BENEFIT INFORMATION:

1. Information below is required for Benefit Submission.
IN ADDITION, the Benefit-Card(s) must be presented at the office visit.

2.  CALL your BENEFIT COMPANY for ITEMS #1-6!!!    Don't "ass-u-me" your card has the correct information!!!
  OFFICE ASSISTANCE OR CALLS regarding these '6-simple-questions' (for corrections or for any compliance)
will be subject to ADA Code D9992. See below ****

3.  We need these '6-little-simple-pieces-of-information' to know your dental-plan benefit---
and so we can submit for you!!  No correct information, and you will NOT BE CONSIDERED COVERED!

4. If you have no dental benefit, enter N/A in required boxes.

1. YOUR GROUP/PLAN SPONSOR---(i.e., WHO OFFERS you the DENTAL PLAN? WHO WORKS WITH the DENTAL CARRIER on the plan ON YOUR BEHALF?------ENTER that EMPLOYER NAME, INSTITUTION, ASSOCIATION, Self-Funded, Dental Office, etc.) -------------------------------------------IF THE DENTAL BENEFIT PLAN IS UNDER ANOTHER PERSON OTHER THAN YOURSELF, BRING THEIR Date-of-Birth & Social Security# to your visit. *

2. NAME of DENTAL CARRIER and/or PLAN? (Delta Dental, Aetna, etc.) *

3. ID #---EVERY BENEFIT MEMBER HAS A NUMBER *

4. GROUP # // POLICY # ? *

5. TOLL-FREE PHONE NUMBER (DENTAL BENEFIT NUMBER ONLY): *

6. DO YOU HAVE A 2nd BENEFIT? IF YES, BRING TO YOUR VISIT THE CORRECT ABOVE INFORMATION FOR THE 2nd BENEFIT---& BRING THIS BENEFIT-CARD ALSO. ----------------------------------------------------IF THE 2nd BENEFIT PLAN IS UNDER ANOTHER PERSON OTHER THAN YOURSELF, BRING THEIR Date-of-Birth & Social Security# to your visit. *

YES NO

I HAVE READ THE 'WELCOME BACK LETTER' & KNOW WHAT TO EXPECT: *

YES

I HAVE READ THE ADDITIONAL ITEMS LISTED ABOVE--AND UNDERSTAND THE PATIENT'S RESPONSIBILITIES BEFORE & WHEN AT THE OFFICE VISIT: *

YES

I UNDERSTAND & RESPECT THAT THESE OFFICE CHANGES HAVE BEEN MADE TO PROTECT ALL PATIENTS, THE OFFICE & THE DOCTOR---AND I UNDERSTAND THAT IT IS OUT OF RESPONSIBILITY & SAFETY FOR MYSELF, THE OFFICE & OTHERS THAT EACH PERSON IS EXPECTED TO COMPLY: *

YES

I UNDERSTAND THAT I MUST SUPPLY THE ABOVE DENTAL BENEFIT INFORMATION (IN ADDITION TO PRESENTING THE BENEFIT-CARD) FOR BENEFITS TO BE SUBMITTED: *

YES

I UNDERSTAND THAT IT IS MY RESPONSIBILTY TO TRUTHFULLY INFORM THE DENTAL OFFICE OF CHANGES IN MY MEDICAL STATUS---AND OF ANY OTHER MEDICAL, BENEFIT OR PERTINENT UPDATES REQUIRED OR REQUESTED BY THE PRACTICE. *

YES

CLICK HERE to SIGN & SUBMIT

   **** Office assistance or calls regarding incorrectly submitted benefit information or for any compliance,
are subject to non-covered ADA Code D9992: Dental Case Management-Care Coordination.
Therefore---be responsible for submitting proper & accurate information in the first place!
  CALL your BENEFIT AGENCY to CHECK your INFORMATION BEFORE SUBMITTING!!

'MASK MOUTH'---What is it?

Contact Us

Complete Dentistry

Contact Form-New Patient Form

​ w e b site by--c l s k e r p a n

'Pre-Appointment Update Form'

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