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Patient Registration Form

Kaufman Family Dentistry

2211 Old Kemp Hwy,
Kaufman, TX 75142
(972) 932-4312

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Home
  •  Cell
  •  Work
  •  Email
  •  Text
Your spouse( * mandatory to fill )
In case of emergency, Contact( * mandatory to fill )
Dental Insurance( * mandatory to fill )
  •  Yes
  •  No

Authorization and Release

I have read and answered the above questions to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance claims.

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health history( * mandatory to fill )
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Please check if you have/had any of the following:

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  •  Aspirin
  •  Pencilin
  •  Sulfa
  •  Local Anesthetics
  •  Codine
  •  Latex
  •  Other

Yearly Updated Signature

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Dental History( * mandatory to fill )
  •  Bad Breath
  •  Sensitivity to Sweets
  •  Sensitivity to Hot/Cold
  •  Broken fillings/loose teeth
  •  Food Collection Between teeth
  •  Sensitivity Biting
  •  Headaches or Migraines
  •  Jaw pain TMJ
  •  Grinding or clenching teeth
  •  Sores in Mouth
  •  Gum/ periodontal disease
  •  Bleeding gums

Smile Analysis

Please help us learn about you and your smile!

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Financial Policy( * mandatory to fill )

Welcome to our office. We are happy to have you as our patient and look forward to offering you and your family outstanding dental care. We know that providing complete comprehensive dental services includes discussing all treatment and financial information.

We encourage our patients to be familiar with the cost of their dental treatment. A fee estimate is available to you before you consent to treatment. If you would like a written estimate, please be sure to request one. 

* Patients without insurance: Please make payment for your care at each office visit. The following payment options are available: Cash or Check, Visa, MasterCard, AMEX, Discover. We also offer financing plans through Care Credit Financing.

* Insurance benefits are determined by your employer, not your dentist. Your insurance policy is a contract between you and your insurance company. We are not a third party to that contract. Your insurance coverage and benefits are your responsibility. Insurance is not a guarantee of payment; it often does not cover all the costs involved in treatment. As a courtesy we will be happy to file your claim for you if you present your dental insurance card and all required employer information. You will be expected to pay for services rendered if this office is unable to verify your insurance information before treatment. (We accept Deita  Dental & Cigna Dental PPO plans)

* Not all services are a covered benefit in all insurance contracts. The insurance coverage purchased by your employer/self-selects certain services they will not cover. You are responsible for deductibles and non-covered services. Please pay estimated portion as services are rendered.

* Separated or Divorced parents of minors; the parent who brings the child in to the dental appointments is responsible for paying the full fee at time of visit. If it is necessary, we are happy to hold a credit/debit number from the non-custodial parent on file.

* To avoid a broken appointment fee, we kindly ask for 24 hour notice for all cancellations.

* If you have any questions or concerns about our financial policies or have any uncertainty regarding insurance coverage, PLEASE do not hesitate to ask. We are here to help you. I have read and agree to the Financial Policy stated above that applies to me.

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