Online New Patient Forms

Venice Endodontist - Michael Sardzinski DMD, PA

Please correct the errors described below.

We are an Out-of-Network dental office. As a courtesy, we will be happy to e-file your claim and your insurance company may directly reimburse you. Please note that payment is due at time of service.

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I understand that all payment is due when services are rendered. I also agree that should my account be referred to a collection service and/or attorney for collection, I will be responsible for all reasonable collection service charges and/or court and other related expenses.

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.

DENTAL HISTORY

MEDICAL HISTORY

Women only:

Please list ALL medications you are currently taking and what each medication is for. (Including OTC, herbs, and vitamins)

Medication

Taking for?

Please list ALL allergies you have, particularly to any medications or drugs.

Allergies

To the best of my knowledge, I have answered every question completely and accurately, and I will inform my dentist of any changes in my health and/or medications.

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.

HIPAA Consent (For Use or Disclosure of Health Information) This form must be completed by the individual whose protected health information is to be disclosed or by a parent or guardian if the person is a minor under state law.

I hereby authorize Dr. Michael Sardzinski to release the following personal health information for:

My Consent

I understand that consent may be revoked by me at any time. I understand why I have been asked to disclose this information and am aware that my patient rights are identified in the practice’s Notice of Privacy Practices.

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.

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