New Patient Forms

PATIENT INFORMATION

Address:

Email:

Please check your preferred number

INSURANCE

Insured person’s name:

Insured person’s employer:

AUTHORIZATION

I authorize and give consent to the performance of dental services for myself (or dependent). I give consent to any necessary or advisable dental procedures, medications, or anesthetic to be administered by the attending dentist or by supervised staff for diagnostic purposes or dental treatment. I understand that using anesthetic agents embodies certain risks.

OUR POLICIES

Payment is due at the time services are rendered unless other arrangements have been made. Returned checks and outstanding balances over 60 days are subject to collections fees and an interest rate of 1.5% per month. If required, also understand a check of credit history may be made.

Appointments cancelled or broken with less than 48 hours of notice may be subject to a $50 cancellation fee. If multiple appointments are missed or cancelled a 50% (non‐refundable) deposit may be required before scheduling future appointments.

I may receive a treatment plan which estimates my portion of payment. If the staff estimates and collects co‐payments and my insurance underpays or denies a benefit, I am responsible for remaining balance.

Not all services are covered in insurance contracts. Insurance companies arbitrarily select certain procedures they do not cover, based upon the premium arranged by my employer.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY AND DENTAL MATERIALS FACT SHEET

I have seen the office notice of privacy practice and dental material’s sheet and may receive a copy at my request.

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