Mark A. Skidmore, DDS-Patient Information

Patient Information Patient Details

First Name*

Last Name*

Middle Name

City*

State*

Zip*

Date Of Birth*

Address*

Gender*

Marital Status*

Social Security Number*

Driving License Number

Patient Information Contact Information

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

Would you like to receive a text message from us to remind you of your appoinment?

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Patient Information Responsible Party's Information

Address*

City*

State*

Zip*

Home Phone Number

Cell Phone Number

Work Phone Number

Work Extension Number

Social Security Number

Driving License Number

Patient Information Emergency Contact Information

Name

Phone Number

Patient Information Primary Insurance Details

Relation To Patient

Name Of Insured

Insured SSN

EmployerName

Insured Person's Address

DOB of Insured

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REM. BENEFITS

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Insurance Company

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Patient Information Cancellation Policy

Our desire is to provide you with the highest quality service and exceptional dental care in a caring and enjoyable atmosphere. We value your time and strive to maintain your appointment at the allotted time, in return, we request the same from you. We will need at least 24 HOURS notice to cancel or reschedule an appointment.

Unfortunately, as a result of the significant increase in short notice cancellations and disregard for appointment confirmations, it has become necessary for us to enforce the following policy.

Failure to provide adequate notice may result in the following:

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If you are more than5-7 minutes late for your appointment, it may be necessary for you to be reschedule and that appointment could be considered a cancellation without adequate notice. PLEASE call if you feel you may arrive later than your scheduled appointment time so that our team can make accommodations to see you.

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a $25.00 fee MAY be accessed to your account and must be paid before being rescheduled.

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Single patient scheduling, only one family member scheduled at a time, If multiple appointments are failed within the same day.

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As a last resort and after MANY failed attempts to schedule appointments, we may have no choice but to dismiss your care from the practice.

**Thank you for your understanding that we are committed to being available to ALL our patients who need dental care.

** I HAVE READ AND UNDERSTAND THE POLICIES ABOVE:

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Patient Information Receipt of Notice of Privacy Policies

Your Privacy Is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

I have received a copy of the Notice of Privacy Practices of M Skidmore D.D.S. I hereby authorize, as indicated by my signature below, to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

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