As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Dental Information

Medical Information

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank you for choosing our practice to serve your dental needs. We appreciate the confidence you have placed in us and will do everything possible to warrant your continued confidence. In order to provide quality service and care to our patients, we ask that you please read and agree to our office policy.

Insurance Policy

Your insurance policy is a contract between you, your employer, and your employer’s insurance company. We are not a part of that agreement. We cannot accept responsibility for negotiating a settlement with your insurance company on a disputed claim.

We will file insurance claims and pre-estimates as a courtesy to our patients. We will do our best to help you maximize your benefits. However, you are responsible for any amount not covered by your insurance.

Please note that insurance pre-estimates are not a guarantee of payment.

We generally accept assignment of benefit from your insurance company but we reserve the right to refuse assignment in certain cases. Full payment will be due at the time of service and your insurance company will reimburse you directly.

When you ask us to submit claims on your behalf, you are agreeing to the following statements:

I authorize and direct payment of the insurance benefit otherwise payable to me, directly to the above named dentist or dental entity.

I understand that it is my responsibility to know what the terms of my insurance are.

I will provide complete and accurate billing information and current dental insurance information.

Payment Policy

If you have dental insurance, your estimated portion may be due at the time of service, but if you do not have dental insurance, payment for service is due in full at the time of service.

Balances older than 60 days will be subjected to collection fees and finance charges at the rate of 1.25% per month (15% annually).

There will be a $50.00 service charge on all returned checks.

Appointment Policy

If it is necessary to modify your scheduled appointment, we request that you give the office 24 hours’ notice. Based on the length of your scheduled appointment, a fee of $50.00 per will be billed for missed appointments.

By signing below I verify that I completely understand, agree, and accept the policies outlined above. I further acknowledge that I am responsible for all dental services rendered me and my dependents (if applicable).

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Patient Screening

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

General Information

Primary Dental Insurance

Secondary Dental Insurance

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.