New Patient Registration Form Patient Details

Please fill out ALL information clearly and accurately.

New Patient Registration Form Contact Information

New Patient Registration Form Emergency Contact Information

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New Patient Registration Form Referral Information

New Patient Registration Form RESPONSIBLE PARTY INFORMATION

(who is responsible for paying any balance?)

  •  Self

New Patient Registration Form Primary Insurance Details

New Patient Registration Form Secondary Insurance Details

New Patient Registration Form Dental History

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New Patient Registration Form Medical History

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Allergies:

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Women:

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New Patient Registration Form Patient Treatment Consent

* I authorize the Dentist(s) or designated staff treating me to perform such diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize the Dentist(s) to perform all recommended treatment and therapeutic procedures to include administering medications as prescribed by the Dentist(s) and mutually agreed upon by me.

* I assign all dental insurance benefits to which I am entitled to the extent permitted under my dental insurance policy(s) to the Dentist. This form also authorizes Baltimore City Dental Group to submit insurance claim forms and receive payment directly from my insurance carrier with the notation "Signature on File". I authorize my Dentist(s) to release treatment records, x-rays and any other information deemed pertinent to my insurance carrier as necessary or requested.

* I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree that any claims the carrier does not pay or any balance that extends beyond 60 days from the date of treatment may be assessed a service charge of 5% per month.

We strive to give each patient a courtesy call one to two days in advance of your scheduled dental visit. However, you are expected to keep your appointment time with or without the courtesy call. Therefore we ask your consideration and that you kindly give 48-hour notice if you are unable to keep your appointment. Please note that if 48-hour notice is not given, there may be a $60 per hour for a broken appointment fee. A broken appointment is a loss to yourself, your dentist and his team members, and to another patient who could have had that appointment time. We reserve the right to terminate your relationship with our office after repeated broken appointments without 48-hour notice.

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I have filled out my New Patient Registration Form to the best of my knowledge.

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I have received Baltimore City Dental Group's Patient Business Policy and Notice of Privacy Practices. I have read, understand and agree to the provisions of the said policies. I understand that by declining to sign, I will not be treated at Baltimore City Dental Group.

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New Patient Registration Form Authorization for Credit Card Use

on

date.

  •  Visa
  •  MasterCard
  •  Discover
  •  American Express
  •  Care Credit
  •  Electronic Check

(Please check the payment method)

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Please fax completed form along with copy of credit card and valid Photo ID to 410-969-9311

New Patient Registration Form Financial Policy (for all patients)

Thank you for choosing Baltimore City Dental Group as your dental care provider. The following describes our Financial Policy. Our office is committed to providing you with the best possible care. Your understanding of our financial policy is an essential element of your care and service. If you have any questions regarding any aspect of our policy, please feel free to present your question to any of our team members.

Payment for services is due at the time services are rendered. We accept cash, debit card, and for your convenience Visa, MasterCard, American Express, Discover and 3rd party financing through Care Credit or Lending Club. Please be advised that we do not accept personal check payments in the office. Our patients who have dental insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service. Payment in advance may be required for certain treatment in order to reserve chair time and fund dental laboratory fees.

Deposit Policy:

  •  Due to the extensive amount of time our staff and doctors devote to preparing and reserving uninterrupted time for appointments over 1 hour, we require a deposit of $100.00 (for each hour reserved).

Appointment Policy (for all patients):

  •  We will work hard to accommodate appointments that fit your schedule and dental needs. We ask that you let us know about changes 48 hours in advance. We do understand that life happens, but any missed appointment without the 48 hour call may be subject to a $50 short/no notice fee, 3 (three) missed appointments are grounds for dismissal from the practice.

All minor patients must be accompanied by an adult (parent or legal guardian). The adult accompanying the minor is required to pay in accordance with our policies. We neither accept third party assignments nor do we recognize or enforce the terms of divorce or child support decrees.

I have read and understand the Financial Policy and Appointment Policy for Baltimore Dental Group and I agree to abide by these policies.

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Insurance Policy and Assignment of Benefits

  •  As a courtesy, we will file the forms necessary to see that you receive the full benefits of your coverage. Because your insurance policy is a contract between you, your employer, and the insurance company, it is your responsibility to make sure we have accurate and up to date insurance carrier information, restrictions of your policy, and billing information. If your insurance company has not paid your claim in full within 45 days the remaining balance will automatically become patient responsibility.
  •  Please be aware some and possibly all of the services provided may not be covered by your insurance provider. Services, which are not covered, downgraded or fall under L.E.A.T (least expensive alternate treatment) by your insurance are your responsibility. Any balance left unpaid after 30 days will be sent to collections, these accounts will accrue a $35 delinquency fee in addition to any past due balance.

I hereby authorize my primary and/or secondary insurance company to make payments directly to Baltimore City Dental Group. Furthermore, I have read and understand the Insurance Policy for Baltimore City Dental Group. I agree to abide by these policies.

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