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Patient Registration Form

Fern Creek Dentistry

1424 Fern Creek Dr, Suite A,
Statesville, NC, 28625
(704) 872-5765

Patient(s) with Dental insurance( * mandatory to fill )
Contact Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
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  •  No
FINANCIAL AGREEMENT( * mandatory to fill )

You are solely responsible for payment to Fern Creek Dentistry for dental treatment rendered even if you are covered by dental, medical or accident insurance. As a service to you, Fern Creek Dentistry will file Insurance claim with your insurance carrier. We ask that you provide our office with correct and/or updated insurance information at each appointment or whenever you have a change in coverage. I hereby authorize payment directly to Fern Creek Dentistry of dental benefits otherwise payable to me.

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Fern Creek Dentistry is authorized to provide any insurance company (s), claim administrator (s), and consulting health care professionals, information concerning health care advice, the purpose of evaluating and administrating claims for benefits. This authorization is valid for the term of coverage of the policy or contract, enforce on this date only, or for two years, whichever is shorter . I know I have the right to receive a copy of this authorization upon request and agree that the photographic copy of this authorization is a valid as the original.

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( * mandatory to fill )

All Patients

In consideration for Fern Creek Dentistry to provide you with dental treatment, you agree all fees and co-payments are due and payable on the day that treatment is rendered to you unless other payment arangements have been agreed to in writing by kClinicName . Cash, Check, Visa* MasterCard*, Discover*, American Express*, and Care Credit*are all acceptable methods of payment.

If your account balance is not paid in full within 30 days of treatment being rendered, you agree to be subject to interest charges of .66% per month (8%apr). In the event that your account becomes delinquent and is not brought current, you understand that in addition to your outstanding balance, you agree to be responsible for all collection costs (33% of balance due) and reasonable attorney fees incurred by or on behalf of Fern Creek Dentistry. You understand that you are solely responsible for payments in full of all account you may have with our office.

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Appointment Policy

Fern Creek Dentistry requires a 24 hours notice to change or cancel an appointment .A first appointment that is broken, cancelled, failed or rescheduled less than 24 hours will not rescheduled. If an existing patient's appointment is cancelled without 24 hours notice same day appointment will only be allowed. I understand I may be dismissed as a patient upon three of these occurrences.

 

I consent to Fern Creek Dentistry using my cell phone number to (choose one or both)

  •  Call
  •  Text

regarding treatment, insurance, and my account . I understand that I can withdraw my consent at any time. My cell phone number is (include area code):

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Acknowledgement of Receipt Notice of Privacy Practices

 

I have reviewed a copy of this office's Notice of Privacy Practices and consent to photos for patient file and/or of treatment.

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At Fern Creek Dentistry we value our patient's time and will make every effort to see patients in a timely manner in relation to their scheduled appointment. If it has been 10 minutes or more past your appointment time, please notify the Front Desk Staff and they will assist you. Additionally if you have commitments immediately after your appointment, please make the Front Desk Staff aware so that we can assist you in maintaining your schedule.

Medical History( * mandatory to fill )
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Allergies

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If Female, Please Answer

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Nearest relative not living with you:

I understand that the information that i have give today is correct to the best of my knowledge.I also understand that this information will be held in the strictest confidence and it si my responsibility to inform this office of any changes in my medical status.

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