Patient Registration Form Patient Details

  •  Policy Holder
  •  Responsible Party

Patient Registration Form Contact Information

  •  I would like to receive correspondence via e-mail.

Patient Registration Form Responsible Party's Information

if someone other than the patient

  •  Responsible Party is also a Policy Holder for Patient
  •  Primary Insurance Policy Holder
  •  Secondary Insurance Policy Holder

Patient Registration Form

  •  Full Time
  •  Part Time
  •  Retired
  •  Full Time
  •  Part Time

Patient Registration Form Primary Insurance Information

Patient Registration Form Secondary Insurance Information

Patient Registration Form Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could h

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  •  Pregnant/trying to get pregnant?
  •  Nursing?
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  •  Pencillin
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  •  Acrylic
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  •  Local anesthetics
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Patient Registration Form TCPA Prior Express Consent Notice

You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using prerecorded/ artificial voice messages and/or use of an automatic dialing device, as applicable. I have read this disclosure and agree that this office, or our assignee, may contact me/us as described above. 

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Patient Registration Form Patient Agreement

We appreciate the value of your time, just as you do! We strive for on-time appointments and a personal, high tech dental experience at each and every appointment. You will have kDentistName undivided attention, as he sees only one patient at a time. Our treatment fees are within the range of other area practices that also provide cutting edge dentistry. Another benefit, and as a courtesy to our patients, we will file your insurance electronically and send any required supporting documentation. Additionally, we will accept assignment of benefits allowing you to pay your estimated portion at the time of service. 

 

ADMINISTRATIVE

 
  •  Text
  •  Email
  •  Phone Call
 

Acknowledgment of HIPPA Information

 

DENTAL INSURANCE

 

We are happy to assist you in obtaining the maximum dental insurance benefits that your policy provides. We will accept an assignment of benefits from your insurance company for the estimated portion of your coverage. Your estimated portion is due and payable at the time of service.

 
  •  I will update my medical history as required.
  •  I hereby authorize kDentistName to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs.
  •  I agree with the use of anesthetics, nitrous, sedatives and other medications as necessary.
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Patient Registration Form HIPAA information and Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. 
 
A Notice of Privacy Practices should be available to you in the office. The notice provides information about how we may use and disclose protected health information about you in order to carry out treatment, payment, and healthcare operations, and for other purposes permitted or required by law. The notice also contains information about your rights under the law. 

Additional information is available from the U.S. Department of Health and Human Services. 

By signing below you understand and agree to the terms of our notice of privacy practices which include: 
 
• Protected health information may be disclosed or used for treatment, payment, or health care operations.
• Authorization is required for certain disclosures of your Protected Health Information. 
• You have the right to opt out of fundraising communications. 
• You have the right to restrict disclosures of your Protected Health Information under certain circumstances. 
• You have the right to be notified of a breach of unsecured Protected Health Information. 

By signing below you understand and agree that: 

• The practice has a Notice of Privacy Practices that you have had the opportunity to review. 
• The practice reserves the right to change the Notice of Privacy Practices and if we change our notice you may obtain a revised copy by contacting our office
• You may revoke this consent in writing at any time and all future disclosures will cease.
• The practice may condition treatment upon the execution of this consent. 

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