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New Patient Sign Up

Please fill out the form below and click the "Submit" button before your first visit, or you may click these links to download the forms and print them out for your first visit:
New Patient Sign-Up
Authorization and Financial Information

* = required
Name:
*
Date:
*
Address:
*
Date of Birth:
*

*

*

*
Marital Status:
SMWD*
Email:
*
Business Phone:
*
Primary Phone:
Secondary Phone:
Employer:
Occupation:
In Case of Emergency Please Contact:
*
Phone:
*
Referred By:
Person Responsible for the Account:
*
Dental Insurance Plan:
Policy Number:
Identification Number:
Insurers Phone Number:

MEDICAL HISTORY

In order to provide you with the best dental care, the following information is necessary

1. Are you having pain or discomfort at this time?Yes  No*
2. When was your last visit to the dentist?
3. Have you been in the hospital during the last 5 years?Yes  No*
    If so, what for?
4. Your physician's name? Phone?
5. Do you taking any prescribed medicines or drugs?Yes  No*
6. Are you allergic to any drugs, medications or specific food?Yes  No*
    If so, what?
7. Have you had abnormal or severe bleeding after tooth extraction, surgery or injury?Yes  No*
8. Do you have shortness of breath or chest pains?Yes  No*
9. WOMEN: Are you pregnant or suspect that you are?Yes  No*
10. Do you have diabetes?Yes  No*
11. Do you have an abnormal heart condition?Yes  No*
12. Have you had rheumatic fever?Yes  No*
13. Have you ever had a heart murmur?Yes  No*
14. Have you ever been told by a doctor that you needed pre-medication before a dental appointment?Yes  No*
15. Do you have high blood pressure?Yes  No*
16. Do you have an abnormal kidney condition?Yes  No*
17. Do you have an abnormal lung condition?Yes  No*
18. Have you ever had a stroke?Yes  No
19. Do you have hepatitis?Yes  No*
20. Do you have HIV?Yes  No*
21. Do you have any artificial joints or valves?Yes  No*
22. Have you ever had an organ transplant?Yes  No*
23. Have you ever taken phen phen or redox?Yes  No*
24. Are you required to carry an Epi Pen, Nitro Glycerin Pills, or an inhaler?Yes  No*
    If yes, which?    Epi Pen    Nitro Glycerin Pills    Inhaler

TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND CORRECT.IF I HAVE ANY CHANGE IN MY HEALTH OR IN MY MEDICATION, I WILL INFORM THE STAFF.

I ALSO AGREE TO ANY BLOOD TEST REQUIRED IN THE STAFF OBTAINS AN INJURY FROM A CONTAMINATED
NEEDLE OR INSTRUMENT DURING MY TREATMENT.

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING:

Patients who are not covered by insurance are expected to pay by cash, check, or credit the day services are rendered.

For those patients who are covered by insurance we will accept assignment of benefits. This means you must agree to:

I. Authorize this office to release any information necessary to expedite claims.
II. Authorize this office to bill your insurance company for services rendered.
III. Authorize payment directly to this office of any insurance benefits otherwise payable to you.
IV.Endorse any payments you receive from your insurance carrier over to this office for services rendered by out staff.

Most dental insurance plans do not cover 100% of the cost of treatment. Because of this and the extreme delay on receiving payment from the insurance company , you will be asked to pay your deductible and your portion of the charges the day the services are rendered. We will estimate as closely as possible your coverage, but until we actually receive the payment from the insurance company, it is just an estimate. We will assist you in dealing with your insurance company, but the ultimate responsibility lies with you. After sixty days the balance will be due in full from you. Account balances which are over 120 days past de will receive 1.5% a month service charge which will be calculated on the 27th of each month based on the present balance.

If patient/guarantor defaults as to any terms of this agreement and this account is referred to an attorney for collection then the patient and/or guarantor/guarantors promises and agrees to pay all collection costs including attorney's fees of 33 1/3% of the principal amount due and owed when turned over for collection and does further agree to pay interest on the unpaid balance from the date that said monies become due and payable.

If requested by you, this office has authorization to forward your radiographs and records to another dentist.

There will be a $20.00 charge on all returned checks.

This office requires a 24-hour notice for cancelled appointments. Patients who fail to show for or cancel their appointments without proper notice will be charged for an office visit.

A photocopy of this authorization shall be considered as effective and valid as the original. Your signature below indicates you understand and agree to the above policies.


Digital Signature (Initials)   

  By entering my initials and name above I authorize this digital signature to be used as my signature.