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Patient Registration Form

Precision Dental

Longford Shoppes at Southern Hills, 6545 S. Fort Apache Rd, Suite 110,
Las Vegas, NV 89148
(702) 331-4444

Patient Details( * mandatory to fill )
  •  Yes
  •  No

(If someone referred you here, please write down their name so we can thank them.)

Contact Information( * mandatory to fill )
  •  HmPhone
  •  WkPhone
  •  WirelessPh
  •  Email
  •  HmPhone
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  •  HmPhone
  •  WkPhone
  •  WirelessPh
  •  Email
Insurance Policy 1( * mandatory to fill )

Please present the insurance card to the receptionist.

Insurance Policy 2( * mandatory to fill )
Medical History for New Patient( * mandatory to fill )

Are you allergic to any of the following?

  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  No
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  •  No
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  •  No
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  •  No
  •  Yes
  •  No

Do you have any of the following medical conditions?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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New patients:

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Dental Release Form( * mandatory to fill )
  •  I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information.
  •  Spouse
  •  Children
  •  Other
  •  Information is not to be released to anyone.

I understand that I have the right to revoke this authorization, in writing, at any time by notifying this office. Such revocation will not affect actions taken by the requesting person prior to the date he or she received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected by this rule. I understand that my health care provider cannot condition treatment on whether I sign this authorization.

Messages

  •  my home
  •  my work
  •  my cell
  •  you may leave a detailed message
  •  please leave a message asking me to return your call
  •  Other
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TREATMENT AGREEMENT( * mandatory to fill )

In order to best serve the needs of our patients, we provide you with an estimate based on the information we have received from you and your insurance company. We strive to accurately determine your co-pay, but unfortunately, are unable to determine exactly to the penny what amounts will be paid toward your dental care. Therefore, please note that this is an estimate. It represents our “best-educated guess” of your co-pay.

We find that many services are either poorly covered or not covered at all by insurance companies and that every insurance plan has its own unique “quirks”, exceptions, limitations, maximums, and fee schedules. Insurance companies never update us as to eligibility and benefits changes.  Their fee schedules and complicated contract language are kept secret. We have to depend on you, the policyholder, to make us aware of benefits, changes, or modifications in your coverage.

All co-payments and deductibles are due on or before the day services are rendered. Any portion ultimately not paid by the insurance company immediately becomes your responsibility. In order for us to assist you in working within your budget, we have worked very hard to make several financial options available to you. Our staff will help you “find a way” to afford this investment in your dental care. We are always available and happy to discuss any financial concerns you may have. Just ask us!

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MISSED OR CANCELLED APPOINTMENT POLICY( * mandatory to fill )

Your appointment is reserved specifically for you. A missed appointment greatly affects the practice due to the loss of an empty appointment slot. A missed appointment impacts the access of other patients to more timely care.

We will make all efforts to reschedule an appointment to meet your needs if given at least 48 hours notice (business days).

Failure to show for an appointment will result in a $25 cancellation fee.

Appointments scheduled for more than one hour will require a $50 deposit that will be applied to treatment. If you are canceling in less than 48 hours, you will lose your $50 deposit.

Anyone who does not show for 3 appointments will be dismissed from the practice.

I have read and understood the above policies.

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