New Patient Registration

Dr. John J. Moynihan

Please correct the errors described below.

RESPONSIBLE PARTY INFORMATION

DENTAL INSURANCE

Add new row

SECONDARY DENTAL INSURANCE

Add new row

PATIENT DENTAL HISTORY

PATIENT MEDICAL HISTORY

FINANCIAL AGREEMENT

This office participates with CareFirst, Delta Dental, and Dents Quest Choice. Patients who carry dental insurance understand that all services furnished are charged directly to the patient and that he or she is personally responsible for payment for all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance. We offer a 5% discount to our patients who pay their treatment plans up front in full.

A service charge of 1 1/2 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. If the account is not cleared, the account will be turned over to collections and a 30% collection fee will be added.

Any checks returned to the office are subject to an additional fee of $25.00. If for any reason you are unable to keep your appointment, 24 hours notice must be given to avoid the 51.00 broken appointment fee.

I have read the above conditions of treatment and payment and agree to their content. All the above answers and information provided are true and correct. If I have any change in my health I will notify the doctors on my next appointment.

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.

Your information will be encrypted.

Loading...