New Patient Form

SS#:
Birthdate: Prev. Visit:

The following is for: the patientthe person responsible for paymentbothnot applicable

Responsible Party This page ONLY needs to be completed if the insurance subscriber is OTHER than the patient AND/OR you are the parent/guardian of the patient

Primary Dental Insurance

Insured's Birth Date:

Insured's Employer Name:

Patient's relationship to insured:SelfSpouseChildOther
Insurance Plan Name:

Insurance Authorization

By checking this box I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Do you have secondary dental insurance? YesNo

Dental Information and Medical History

How would you rate the condition of your mouth?

ExcellentGoodFairPoor

Previous Dentist Name and Phone Number

Approximate date of most recent dental exam and/or dental x-rays

I routinely see a dentist every 3 mos4 mos6 mos12 mosNot routinely

What is your immediate concern about your dental health?

Is there anything about the appearance of your smile that you would like to change?

If any of the checked boxes need further explanation, please describe:

Please clarify the conditions or alerts selected including due date if pregnant:

Do you take antibiotic premedication for your dental visits? If yes, please explain.

Describe any current medical treatment, recent hospitalizations and recent or impending surgery.

Name of physician and date of last physical exam

Name and phone number of preferred pharmacy

Are you taking any medications (prescription and Non-prescription) if yes please explain below *

Do you have any allergies and/or allergies to medications. If yes, please explain below*

By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. I further consent to the performing of xrays and oral examinations. This will serve as my electronic signature

Name of Patient/Parent or Guardian completing this form*

Consent for Services and Financial Policy

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. As a curtesy, we will file your insurance claims and the insurance company will pay us directly. This is not a guarantee of payment from the insurance company and any amount not paid by patient insurance is the responsibility of the patient.

I understand that any fee estimate for this dental care can only be extended for a period of 30 days from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (7) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

When you schedule an appointment, we reserve that time specifically for you. We require at least a 48 hour notice of cancellation or a minimum of at least $40 no show charge may be incurred.YesNo

*By checking this box, I understand the above information and agree with its contents and this will serve as my electronic signature for the Administration Form.

HIPAA Acknowledgment/Consent for Internet Communications

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release i have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

I authorize this dental practice to release any financial or dental information to the following person(s) listed below:
*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.
I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES

*I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.