Guthrie Family Dental-Patient Registration Form

Patient Registration Form Patient Details

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First Name*

Last Name*

Middle Name

Date Of Birth*

Address*

City*

State*

Zip*

Is patient a child?

Yes
No

Parent name

Social Security Number

How did you hear about us?

Patient Registration Form Contact Information

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Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Would you like to receive text message reminders about your appointment?

Yes
No

Patient Registration Form Primary Insurance Details

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Insurance Company

Name of Insured

Insured SSN

Employer Name

DOB of Insured

Group Number

FAQ:

Q: Who is the subscriber/ policy holder?

A: Whoever has the insurance in thier name (through job or other source)

Q: What if I don't have a subscriber ID#?

A: Most insurance will use the SS of the subscriber if a subscriber ID is not specified

For any other question on insurance call us at 816-443-5479!

Patient Registration Form Financial Policy

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PLEASE READ THE FOLLOWING POLICIES AND SIGN AT THE BOTTOM TO INDICATE THAT YOU HAVE READ AND UNDERSTAND OUR OFFICE FINANCIAL POLICIES TO THE BEST OF YOUR ABILITY.

Patients with Insurance

We will gladly verify your dental benefits and process your primary and secondary insurance claims with the following agreement:

* Your dental insurance is an agreement between you and your insurance company.

* All patient copayments and/ or patient portions are only an estimate, never a guarantee of payment

*As part of your contract with your insurance company, you are responsible for all out of pocket portions/ copayments and deductibles.

* Insurance payments not paid after 90 days will become your responsibility and must be paid in full.

* Please be prepared to show your insurance card at the time of your visit.

Payment Agreement/ Options

YOUR (ESTIMATED) BALANCE IS DUE AT TIME SERVICES ARE RENDERED.

* For your convenience, we accept Visa, Mastercard, American Express, Discover, ApplePay, Check, and Cash.

* CareCredit, specializing in helping patients finance larger dental or orthodontic cases. No down payment is required and payments can be made in 6-18 months with no interest rates. One of our team members would be happy to help fill out an application. You must qualify to use this financing option.

* We reserve the right to charge a $25.00 fee on all returned checks.

* After 90 days, all accounts that are not paid in full may be sent to a third-party collection agency.

Deposit Policy

Due to the extensive amount of time our staff and doctors devote to preparing and reserving uninterrupted time for reservations over 2 hours, we require a deposit of half of the treatment fee to make your reservation.

Cancellation Policy

Due to the fact that we are reserving time on our schedule for your appointment, we ask that you provide 2 business days notice for any appointments that you may need to change. All changes in your scheduled appointment must be handled during our normal business hours. This courtesy on your part will make it possible to give your appointment to another patient who needs to see the dentist or hygienist.

We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Most often, financial misunderstandings can be managed with a phone call. Please feel free to contact our wonderful staff at any time to discuss any concerns you may have.

SIGNATURE (Patient Signature)*

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Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form

Patient Registration Form Primary Insurance Details

Patient Registration Form Medical History

Patient Registration Form Financial Policy

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