Patient Registration Form Patient Information

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 questions  we'ii be glad to help you. We look forward to working with you in maintaining your dental health. 

Patient Registration Form Patient Information

Patient Registration Form Primary Insurance

Person responsible for account

Patient Registration Form PRIMARY INSURANCE

Patient Registration Form ADDITIONAL INSURANCE

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  •  No

Patient Registration Form ADDITIONAL INSURANCE

Patient Registration Form DENTAL HISTORY

Check Yes or No if you had problems with any of the following 

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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 have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
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  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
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Do you have, or have you had, any of the following?
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Patient Registration Form FINANCIAL POLICY

Thank you for choosing us as your dental health care provider. We are committed to your treatment being successful. The following is a statement of our Financial Policy which requires you to read and sign prior to any treatment.

All patients must complete our lnfonnation and Insurance form before seeing the doctor.

FULL PAYMENT IS DUE AT TIME OF SERVICE.

WE ACCEPT CASH, CHECKS, VISA/MASTER CARD, AMERICAN EXPRESS and CREDIT CARDS.

 

REGARDING INSURANCE

Payment in full is required at the time of service. However, we may accept assignment of insurance benefits. If payment in full is not required, we will require your co-pay to be paid at the time of service. We cannot submit your insurance claim unless we have all insurance information and an original claim form. Failure to do so prohibits any submission and the entire balance will be immediately due and owing. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, the balance will be automatically transferred to your account. The balance is your responsibility whether your insurance company pays or not. Please be aware some of the services provided may be non-covered services by the Insurance Program and/or other medical insurance. 'I'his is not a statement by the insurance company that the service was unnecessary but rather a reason for rejection of payment by the insurance company. You are responsible for payment of all services rendered. All accounts due over sixty ( 60) days are subject to a 1.5% monthly finance charge.


USUAL AND CUSTOMARY RATES

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.


MISSED APPOINTMENTS

 

Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at a 50% rate. Please help us serve you better by keeping scheduled appointments. 

I have read the Financial Policy. I understand and agree to this Financial Policy.

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Patient Registration Form Emergency Contact Information

Patient Registration Form AUTHORIZATION

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriale and healthful dental treatment. If there ls any change in my medical status, I will lnform the dentist.

I authorize the insurance company Indicated on this form to pay to the denllst all insurance benefits otherwise payable to me for services rendered.I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment or benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment is due in full at time of treatment, unless prior arrangements have been approved.

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