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Patient Registration Form

Babin Dental

10631 Hillary Court,
Baton Rouge, LA, 70810
2255903836

About You( * mandatory to fill )

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions or need assistance, please ask us - we will be happy to help.

Responsible Party's Information( * mandatory to fill )

Spouse Information

Emergency Contact

Dental Insurance Information( * mandatory to fill )

Primary Insurance

Secondary Insurance 

Patient Health Information( * mandatory to fill )

Dental History

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Medical History( * mandatory to fill )
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Please list your family physician and any medical specialists you see at least once a year:

Check any of the following which apply in either the PAST or PRESENT:

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  •  Local Anesthetics
  •  Aspirin
  •  Penicillin or Other Antibiotics
  •  Metals
  •  Latex (Rubber)
  •  Iodine
  •  Sulpha Drugs
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Babin Dental LLC requests this information for the purpose of providing a complete and comprehensive evaluation of your dental needs. No persons outside the practice will be provided with this information unless properly authorized by you or required by law. Failure to provide the requested information will limit our ability to assess your needs and may result in our practice being unable to accept you as a patient. By signing below, you agree that the information given is accurate and that you will notify our office at subsequent appointments if there are any changes in your health.

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If you should need restorative treatment, we require a $50 deposit to reserve your spot on the operative schedule. This will be applied towards your portion of treatment. Thank you!

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NOTICE OF PRIVACY FOR PROTECTED HUMAN INFORMATION( * mandatory to fill )

I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I understand that I may ask any questions I might have regarding this notice.

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FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

  •  Individual refused to sign
  •  Communication barriers prohibited obtaining the acknowledgement
  •  An emergency situation prevented us from obtaining acknowledgement
  •  Other

Insurance Authorization/Assignment

I hereby authorize Babin Dental LLC to furnish to my insurance carriers any information necessary to process any claim for services rendered by either Drs. Babin. I hereby assign to these same dentists any insurance benefits payable for services rendered to my dependents, or myself but not to exceed my indebtedness to Babin Dental LLC. I understand I am financially responsible for all services rendered regardless of insurance coverage.

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Appointments

We value your time so you can expect us to see you at the appointed occasion and to keep your period spent in our office as short as possible. In return, when you make an appointment with us please be on time since we have reserved our time just for you. Please make every effort not to change your scheduled appointment. If you must change an appointment, please provide us at least 2 working days advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patient and our practice. Missed appointment will result in a $25.00 fee. We value your time. Please value ours.

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Financial Policy( * mandatory to fill )

Dental insurance plans often pay less than the actual fee for service, therefore the patient or guarantor is the responsible party for all dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be explained to you during the Treatment Discussion appointment. Your estimated patient option is only an approximation and is based on your estimated insurance benefits. We are NOT responsible for any agreement between you and your insurance company. As a courtesy to you, we will be happy to file with your insurance company. To keep our fees to you as low as possible, we ask that you pay your ESTIMATED copayment at the time you receive treatment. Also, we do not downgrade fees or insurance code changes (any difference in fee will be your responsibility). We allow 45 days for your insurance to pay and then you, the responsible party, will be required to pay any remaining balance.

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Unless another financial option is PRE-ARRANGED, payment in full is due the day of treatment, or on pre-op visits for sedation appointments. If a procedure requires multiple appointments, payment is required in full at the first appointment. Should a patient have dental insurance with assignment to Babin Dental LLC, the estimated patient portion will be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full. Should it become necessary any attorney fees, court costs, and collection fees become my responsibility and will be added to my account.

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Payment Options

1. For your convenience we accept Cash, Check, Visa, MasterCard, Amex, and Discover.

2. You can also apply for a financing option at our office with Care Credit with a monthly payment plan that is interest free for a year. You can select the payment date that works best for your budget.

Release of Information

I authorize Babin Dental LLC to release any information regarding my dental or medical history, diagnosis or treatment to the third party payers and/or health professionals.

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