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Patient Intake Form

Harmony Dental Arts

1066 Clifton Ave, Clifton,
Clifton Ave, NJ, 07013
(973) 777-2731

Patient Information( * mandatory to fill )
Employer Information( * mandatory to fill )

 

 

Primary Dental Insurance( * mandatory to fill )
  •  Self
  •  Spouse
  •  Child
  •  Other
Secondary Dental Insurance ( * mandatory to fill )
  •  Self
  •  Spouse
  •  Child
  •  Other
Medical and Dental History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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Medical and Dental History( * mandatory to fill )
  •  3 (+) a day
  •  Twice a day
  •  Once a day
  •  Weekly
  •  Seldom
  •  1 (+) a day
  •  2 - 6 weekly
  •  1 - 6 monthly
  •  Seldom
  •  Never

Please mark any of the following to indicate Yes in response to the question:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
Primary InsuranceDetails( * mandatory to fill )

 

 

Financial Policy( * mandatory to fill )

-We will accept assignment of your insurance benefits at the time of your visit(s). However, we do require your co pay and deductible at the time of service. Also, you will be billed for any amount that your insurance states is not dentally necessary and/ or are not covered under your contract. Insurance is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible, coinsurance, or any other balance determined by your insurance company to be your responsibility.If payments are 30 days late or more you will

-The adult accompanying a minor and the patient (or guardian of the minor) is responsible for payment. For unaccompanied minors, non-emergency treatment will

 

-In case of rescheduling or cancelling appointments, a minimum of 24 hr is required to avoid a $75 fee unless it is true emergency.

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