New Patient Form - Children age 12 & under

Patient Registration

First Name

Last Name

Middle Initial

Preferred Name

Patient is

Policy Holder

Responsible Party

Neither

Responsible Party (if someone other than the patient)

First Name

Last Name

Middle Initial

Address

Address 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Date of Birth

Drivers License

Social Security #

I allow Michelle B. Deutch Family Dentistry to send text messages and or emails to the methods of contact I've provided.

Yes

Responsible Party is

Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Policy Holder

Patient Information

Address

Address 2

City

State

Zip

Home Phone

Work Phone

Cell Phone

I allow Michelle B. Deutch Family Dentistry to send text messages and or emails to the methods of contact I've provided.

Yes

Sex

Male Female

Marital Status

Single Married Divorced Separated Widowed

Birth Date

Age

Social Security

Drivers License

Email Address (For Patient Confirmation of appointments and specials)

Accepts Text Message

Previous Dentist

Phone Number

Preferred Pharmacy

Phone Number

Employment Status

Full Time Part Time Retired

Student Status

Full Time

Part Time

Employer

Occupation

Employer Address

Insurance Information

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

Signature

Child's Name

Birth Date

Nickname

School

Hobbies

Who is accompanying the child today?

Relationship to child

Reason for today's visit?

Last Dental Visit?

Has the child ever had a serious/difficult problem associated with previous dental work?

Child’s Physician

Phone Number

Date of Last Visit

Please list current medications child is taking

List all drug allergies

Please describe the child’s current physical health.

Good Fair Poor

I affirm that the information I have given is correct to the best of my knowledge. It will be held in strictest confidence.
I authorize the dental staff to perform the necessary dental services my child may need.

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

Signature of parent or guardian

Date

Medical History

Patient Name

Date of Birth

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes No

If yes, explain

Have you ever been hospitalized or had a major operation?

Yes No

If yes, explain

Have you ever had a serious head or neck injury?

Yes No

If yes, explain

Are you taking any medications, pills, or drugs?

Yes No

If yes, explain

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

If yes, explain

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

If yes, explain

Are you on a special diet?

Yes No

If yes, explain

Do you smoke or chew tobacco?

Yes No

If yes, explain

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Metal

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

Other

List any Other allergies below

Do you use controlled substances

Yes No

If yes, explain

Have you ever had any serious illness not listed?

Yes No

If yes, explain

Comments

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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

Signature of Patient, Parent or Guardian:

Date

Notice of Privacy Practices Acknowledgement

Michelle B. Deutch, D.D.S.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement
I have received a copy of this office’s Notice of Privacy Practices. (https://www.dentistryoverlandpark.com/docs/HIPPA1.pdf)

Name

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

Signature

Date

Financial Policy

Thank you for choosing us as your dental health care provider. We look forward to assisting you in attaining optimum oral health.

Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy, which we require that you read and sign prior to any treatment. All patients must also complete our Patient Information Form as well as your insurance form, if required by your plan, before seeing the doctor.

Full Payment Is Due At The Time Of Service unless other financial arrangements have been made in advance. We accept cash, check, American Express, Master Card, Visa, and Discover cards. Other financial services are available through Care Credit.

A monthly billing fee of 1.5% or $5.00, whichever is greater, will be added to all accounts that remain unpaid after 60 days. If it becomes necessary to use other means for collecting payment, the patient is responsible for any and all costs, fees, and attorney fees incurred.

Regarding Insurance
Our office requires that you pay your deductible and co-payment, if applicable, at the time of service. While every effort will be made to maximize your insurance benefits, the balance is your responsibility, whether your insurance company pays or not. If your insurance company has not paid your claim within 60 days, the balance will be automatically billed to you. Please be aware that some and perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under your policy.

We will file insurance claims for you if you bring all insurance information and a completed insurance claim form, if required by your plan. Information regarding insurance benefits is the responsibility of the patient. Estimates given by our office are not a guarantee of benefits. We cannot be held responsible for the benefits paid, or not paid, by your insurance company.

Emergency Care
All emergency care patients are expected to remit payment at the end of the appointment.

Missed Appointments
Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. Please have the courtesy to give us at least 48 hours notice so that we may help serve other patients wanting treatment.

Thank you for understanding our Financial Policy. Please let us know if you have any
questions or concerns.

I have read this Financial Policy, and understand and agree to this Financial Policy.

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

Name

Signature of Patient or Responsible Party

Date

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Dr. Michelle Deutch to use or disclose my Personal Health Information (PHI) as described below. I understand that, if the organization authorized to receive my PHI is not a health plan or health care provider, the released PHI may no longer be protected by federal privacy regulation. Our Notice of Privacy Practices provides detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practice. It is available upon request.

Patient authorizes communication with family/friends regarding your care and test results.

Additional authorized party

Patient authorizes communication with family/friends regarding your account and billing.

Additional authorized party

Patient authorizes communication with a primary care physician or other physicians (first and last name):

Additional Physician

Best way to contact you regarding messages, responses, appointment reminders etc. (mark all that apply).

Home Phone

Work Phone

Cell Phone

May we leave a message with whomever answers the phone or on voicemail?

Yes No

I allow Michelle B. Deutch Family Dentistry to send text messages and or emails to the methods of contact I've provided.

Yes

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your PHI in reliance on your consent.

May we fax and/or email to other providers if necessary for medical care?

Yes

N/A

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

Signature of patient (or patient’s representative)

Date

Credit/Debit Policy

Patient Name

I understand it is the policy of Michelle Deutch, D.D.S. to secure my credit or debit card information at the time of my visit. The office acknowledges that we must comply with the provisions of the U.S. law.

If, after a claim has been submitted to my insurance carrier: 1) the claim is denied for any reason: OR 2) there is a patient liability (I.E. Deductible, Co-insurance, etc.) the office will send a statement notifying me of the balance. If this amount is not paid within 60 days, then my credit or debit card will be charged for the entire balance owed for treatment of services to me.

I understand my insurance company will also provide notification of these charges with an explanation of benefits. In the event this amount exceeds $250.00, the office will provide a courtesy call to my phone number.

I understand that in the event my credit or debit card has been charged for treatment or services, and then my insurance carrier subsequently makes a payment to the office for those charges, the office will issue a credit to my credit or debit card.

Please select one of the following:

Visa Mastercard American Express Discover

Card/Account Number

Expiration Date

Security Code

Name of Cardholder

I hearby authorize Michelle B Deutch, D.D.S. and its designated employees to charge my credit/debit card as designated above.

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

Cardholder's Signature

Date

Your information will be encrypted.