NEW PATIENT FORM


Patient Information

  • Date
  • Patient Name
  • Gender
  • Family Status
  • Social Security Number
  • Birth Date
  • Cell Phone
  • Home Phone
  • Email
  • Address
  • City
  • State/Province

Health Information

  • Date Of Last Dental Visit
  • Reason For the Visit
  • Have you ever had any of the following? 
  • List any other condition you ever had
  • List all the medications you are currently taking
  • Have you been admitted to a hospital or needed emergency care during the past two years?
  • Are you now under the care of a physician?
  • Do you have any health problems that need further clarification

Referral Information

  • Whom may we thank for referring you to our practice?

Insurance Information

  • Insurance Name
  • ID Number
  • Group Number
  • Insurance Phone Number
  • Name of Insured
  • Patien's Relationship to Insured
  • Is insured a patient?
  • Insured's Birth Date
  • Insured's Employer Name

Acknowledgment Of Receipt of Notice of Privacy Practices

  • Address
  • I , have received a copy of this office's Notice of Privacy Practices. 

Consent For Services

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

    All emergency dental services, any dental services performed without previous financial arrangements, and any co-payments must be paid for at the time services are performed.

    A charge will be made for broken appointments unless 48 hours prior notice is given.

    Patients who carry dental insurance understand that all dental services furnished 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 such 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.

    The insurance estimates are according to information provided to us by your insurance company, they are in no way a guarantee that services will be covered. Our office is happy to bill your insurance company for you and accept assignment of benefits, but the entire bill ultimately remains the patient’s responsibility. It is up to the patient to resolve any conflicts with their 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 the fee estimate listed for this dental care can only be extended for a period of three months or less from the date signed.

    In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. 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 at home or at my work to discuss matters related to this form.

    I have read the above conditions of treatment and payment and agree to their content.

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Signature Certificate
Document name: NEW PATIENT FORM
lock iconUnique Document ID: 408cec3e5214d19e63a30ff2a2c2be96f425d578
Timestamp Audit
Feb 3, 2022 12:09 pm CSTNEW PATIENT FORM Uploaded by Dr. Divya Sankepally - info@justsmilezdental.com IP 45.44.67.113
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