Patient Registration

Please correct the errors described below.

We are pleased to welcome you and your child to our practice. Our goal is to educate, motivate, and promote good oral health that will last a lifetime. Please take a few minutes to fill out this form completely. Please mark “SAME” or “N/A” where appropriate.

Patient Information

Parent/Guardian Information

If no, please name the legal guardian / responsible

Child’s Dental History

Child’s Medical History

Insurance Information

Acknowledgement

I attest that the information that I have given is accurate to the best of my knowledge. It is my responsibility to inform the office of any changes in my child’s health or other information

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.

Acknowledgement of Receipt of Notice of Privacy Policies

(Minor)

I have received a copy of the Notice of Privacy Practices of Beech Lake Pediatric Dentistry. I hereby authorize, as indicated by my signature below, Beech Lake Pediatric Dentistry to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

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.

Please check your preferred means of communication

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,
but acknowledgement could not be obtained because

Patient Consent (MINOR)

Clinical

(“Patient”)

I authorize Beech Lake Pediatric Dentistry to perform all recommended treatment on the Patient.

2. I authorize the Practice to take radiographs, study models, photos, and other diagnostic aids or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis. I authorize that such Diagnostic Material may be released to third-party payors and/or other health professionals

3. I authorize the use of anesthetics, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination.

4. I authorize the following individual(s) the authority to transport and/or accompany my child to their dental appointments in my absence. I furthermore agree that the individuals listed below have my full authority to authorize changes in my child’s dental treatment. I further authorize the discussion of the patients Protected Health Information (PHI) to the below-listed persons. This includes, but is not limited to, medical information/conditions, different filling types, extraction of teeth, conscious sedation, and all other forms of dental treatment. I understand that any changes made to my child’s treatment plan can result in changes to the amount of money owed to the dental office, and I agree to be fully responsible for any additional fees incurred. I understand that I can revoke this permission at any time, but this must be done by WRITTEN notification.

Add Additional Name

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.

5. I understand that Dr. Burke and his staff might use behavior management techniques such as praise, child appropriate language, demonstration of procedures and instruments, and variable voice tone to aid in cooperation during dental treatment

Financial

6. I am responsible for payment for all services rendered on behalf of the Patient. I understand that payment is due when services are rendered. I am aware that a 1.5% MPR or 18% APR is automatically tabulated into my account if my balance is 60 days old or older. Balances over 90 days will be turned over to a collection agency; Should my account become delinquent, I will be responsible for all additional collection costs including reasonable attorney fees.

7. We accept cash, checks, debit cards, Visa, and MasterCard.

8. If a check is returned NSF, there will be a $25.00 check return fee; from that point on, checks will not be accepted. A drivers license number will be required on all checks.

9. We also offer financing through a separate company (CitiHealth and CareCredit). This, however, requires credit approval from an outside agency and minimal monthly payments. If you are interested in this program, ask one of our front office staff for more information.

10. I am aware that to hold down operating costs, 24 hours notice of cancellation is required. A missed appointment charge of $50.00 may be applied to your account if less than a 24 hour notice is given.

Insurance

11. I authorize the Practice to release to staff, hospitals, health care service plans, insurance companies, self-insurers or their representatives, any and all information, records, and radiographs about the Patient’s medical history, services rendered, or recommended treatment.

12. I authorize the Practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my behalf or on Patient’s behalf and in my name listed as “signature on file” and assign to the Practice the insurance benefits providing assignment is accepted. I am responsible for payment regardless of the coverage provided.

13. Patient's portion of payment is due at the time of service. We will gladly submit your insurance claim for you;

however, we do require any deductibles, co-payments, and "estimated" patient portions be paid at the time of service. PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. WE ALSO CANNOT BE RESPONSIBLE FOR ANY ERRORS IN FILING YOUR INSURANCE. Once again, we file claims as a courtesy to you.

14. I understand that my dental insurance plan is designed to only share in my dental costs, usually covering 50-80% of the total dental bill. I understand that some dental services may not be covered by my insurance plan. I understand the amount of dental benefits I receive is determined by my employer or my insurance company, not by the dental clinic. I understand it is my responsibility to review my insurance policy and to understand my specific dental benefits.

15. In the event my insurance company has not paid their portion within 60 days, the balance of the bill will become my responsibility.

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.

I have read this Patient Consent and agree to the terms and conditions herein.

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.

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