New Patient Registration Patient Details

New Patient Registration Contact Information

New Patient Registration Emergency Contact Information

New Patient Registration Dental Insurance

Primary Dental Insurance:

Insurance Authorization:

  •  By checking this box

I authorize my insurance to pay my benefits directly to the dentist for all services rendered.

I authorize the use of this electronic signature on all insurance submissions.

I authorize the dentist 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.

(Please click below to draw/upload sign)
(Your IP Address :IP:34.205.93.2 )

New Patient Registration Medical History

Indicate which of the following you have had or have at present.

  •  Yes
  •  No
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  •  By checking this box, I acknowledge that the above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.
(Please click below to draw/upload sign)
(Your IP Address :IP:34.205.93.2 )

New Patient Registration Dental Information

  •  Excellent
  •  Good
  •  Fair
  •  Poor
  •  3 mo
  •  4 mo
  •  6 mo
  •  12 mo
  •  Not routinely
  •  1
  •  2
  •  3
  •  4
  •  5
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  •  8
  •  9
  •  10
(Please click below to draw/upload sign)
(Your IP Address :IP:34.205.93.2 )

New Patient Registration Dental Practice Financial Policy

I hereby agree to be responsible for the costs of care provided by Sarasota Bay Dental and/or the dental team for myself or my dependent(s). These include any deductibles and amounts not covered by insurance. I also understand that it is my responsibility to be aware of any limitations, and benefits of my insurance policy. Payment to this office is my responsibility and I am aware that if the insurance company does not reimburse the doctor. I am responsible for the total amount(s).

  •  By checking this box, I acknowledge that I have read, and fully understand and agree to the terms of this Financial Policy

Notice of Privacy Practices Acknowledgment.

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

I authorize this office to disclose or discuss my personal and/or dental information with the following person(s).

(Please enter name and relationship to patient.) 

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.
(Please click below to draw/upload sign)
(Your IP Address :IP:34.205.93.2 )

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