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Patient Registration Form

TruCare Dental

3031 South 1st Street Suite 400,
Garland, TX 75041
(972) 864-0000

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  the patient
  •  the person responsible for payment
  •  both
  •  not applicable
Responsible Party Information( * mandatory to fill )

This only needs to be filled out if the insurance subscriber is other than patient, or if patient is under 18.

  •  the patient's spouse
  •  the person responsible for payment
  •  both
  •  neither-not applicable
Primary Dental Insurance( * mandatory to fill )

Insurance Authorization:

  •  By checking this box,

I authorize my insurance company to pay the dentist all insurance benefits 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.

Secondary Dental Insurance( If no secondary insurance, skip to next page)( * mandatory to fill )

Insurance Authorization:

  •  By checking this box,I authorize my insurance company to pay the dentist all insurance benefits 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.

Medical History( * mandatory to fill )

Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.

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  •  Excellent
  •  Good
  •  Fair
  •  Poor
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  •  No
  •  By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.
Dental Information( * mandatory to fill )
  •  3 mo.
  •  4 mo.
  •  6 mo.
  •  12 mo.
  •  Not routinely
  •  Had an unfavorable dental experience
  •  Had any reactions to local anesthetic
  •  Had any teeth removed
  •  Had complications from past dental treatment
  •  Had/have braces, orthodontic treatment
  •  Had trouble getting numb
  •  Had your bite adjusted
  •  Is there anything about the appearance of your teeth that you would like to change?
  •  Have you ever whitened (bleached) your teeth?
  •  Have you felt uncomfortable or self conscious about the appearance of your teeth?
  •  Have you been disappointed with the appearance of previous dental work?
  •  You have problems with your jaw joint
  •  You have problems chewing
  •  Your teeth changed in the last 5 years, become shorter, thinner, or worn
  •  Your teeth are crowding or developing spaces
  •  You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
  •  You clench your teeth in the daytime or make them sore
  •  You have problems with sleep or wake up with an awareness of your teeth
  •  You wear or have worn a bite appliance
  •  Cavities within past 3 years
  •  The amount of saliva in your mouth seems too little or you have difficulty swallowing any food
  •  You notice or have holes (i.e. pitting, crates) on the biting surface of your teeth
  •  Any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth
  •  Grooves or notches on your teeth, chipped teeth, or had a toothache or cracked filling
  •  Food gets caught between any teeth
  •  Gums bleed when brushing or flossing
  •  Treated for gum disease or were told you have lost bone around your teeth
  •  Noticed an unpleasant taste or odor in your mouth
  •  History of periodontal disease in your family
  •  Experienced gum recession
  •  Had any teeth become loose on their own (without injury), or have difficulty eating an apple
  •  Experienced a burning sensation in your mouth
Consent for Services and Financial Policy( * mandatory to fill )

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.
(Please click below to draw/upload sign)
(Your IP Address : IP:3.95.131.97 )
Consent for Cancellation and No-Show( * mandatory to fill )

At TruCare Dental, our patient is scheduled and seen each week. Once you scheduled an appointment with TruCare Dental, that time is reserved exclusively for you. Unfortunately, when a patient doesn't show up for their scheduled appointment, another patient loses an opportunity to be seen. In order to successfully operate our practice, we need to be able to rely on these dental appointments. Therefore, we have established the following policy for missed, no-show, and cancelled appointments.

For any appointment that is missed, no-show or canceled with less that required 24 hour notice, patient will be charged with a fee and it must be paid in full before next appointment. Also keep in mind that missed or late canceled appointments are not covered by your dental insurance plan and cannot be billed to your insurance company.

* No Show- $25

* Cancelation less than 24hrs- $25

We understand that special unavoidable circumstances may cause you to cancel within 24 hours. If you call our office after hours, please leave a message to cancel or reschedule and we will confirm with you by phone on the next business day. Fees in this instance may be waived but only with management approval

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.
(Please click below to draw/upload sign)
(Your IP Address : IP:3.95.131.97 )
HIPAA Acknowledgement( * mandatory to fill )

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,

  •  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:3.95.131.97 )
Consent for Internet Communications( * mandatory to fill )

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

  •  I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.
(Please click below to draw/upload sign)
(Your IP Address : IP:3.95.131.97 )
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