Existing Patient Paperwork

Last Name:

First:

Middle Initial:

Date of Birth:

Previous Visit

Email address

Home Phone No.

Work Phone No.

Mobile Phone No.

Best time to call

Address 1

Address 2

Name of Insured

Insurance Plan Name

Insurance ID No.

Please explain/clarification any conditions or alerts selected above.

Conditions / Alerts

Allergies not listed

Reason for Pre-Med and Date

Name of your Physician and Phone Number

Preferred Pharmacy, Location and Phone Number

Name and Number of Emergency Contact

Please list authorized person/s with whom we may discuss your Protected Health Information in addition to custodial parents and / or legal guardians. If no one enter none

Are you currently taking any medications (prescription and non-prescription) including regular doses of aspirin? If yes, please list all medications and dosage below

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature or Name of Patient, Parent or Guardian completing this form

Relationship to Patient

Date

**IMPORTANT**

We require a 24-hour confirmation for all appointments. On any appointment 90 minutes or longer we require 48 hours' notice if you need to cancel or reschedule. WE REQUIRE ALL APPOINTMENTS TO BE CONFIRMED. If we do not receive a confirmation for your appointment we will consider you are not coming to your appointment and will find that spot. We do have an answering service that is available for you to leave a message if our office closed or we can not be reached

If you NO SHOW OR CANCEL with less than 24 Hour notice for a cleaning appointment, we will be REQUIRED to pay a $25 deposit to reach out

We REQUIRE a 24-hour notice to cancel or reschedule to avoid losing your deposit. A new deposit will be required to reschedule an appointment.

Our NO SHOW or CANCELATION fee is $50 and must be paid to reschedule an appointment. Please CONFIRM your appointments to potentially avoid losing your reserved time.

There is a 3% surcharge for CREDIT transactions. No charge for DEBIT or CASH. WE DO NOT ACCEPT CHECKS

After 2 missed appointments, you will be REQUIRED to pay your visit in full to reschedule.
After 3 missed appointments, you will be dismissed from the practice.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature or Name of Patient, Parent or guardian completing this form

Relationship to Patient

Date

Your information will be encrypted.