Adult Patient Registration Form

Responsible Party ( if someone other than the patient )

Patient Information

Primary Insurance Information

Secondary Insurance Information

Eaglesoft Medical History

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

Women: Are you...

DIABETES

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. Its 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.

PATIENT CONSENT

Adult & Acknowledgement of Receipt of Privacy Practices

Clinical

I authorize the Practice to perform all recommended treatment, including but not limited to:

1. All recommended treatment
2. Radiographs, study models, photos, and other diagnostic aids or materials (collectively, Diagnostic materials) as needed to make a thorough diagnosis.
3. The use of anesthetics, nitrous oxide, sedatives, and other medication, as needed, and I'm 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 lock of coordination.

Financial

2. I am responsible for payment for all services rendered. I understand that payment is due when services are rendered. I am aware that a 1.5% MPR or 18% APR automatically tabulated into my account. if my balance is 30 days old or older. Should my account become delinquent, I will be responsible for all additional collection costs, including reasonable attorney fees.

Maintaining Appointments

3. I am aware that when appointments are broken or cancelled at the last minute, valuable clinical time is voided, time that could have been spent serving another patient, especially a patient in pain. I am aware that to hold down operating costs, 24-hour notice of cancellation is required.

Insurance

4. I authorize the Practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my 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 coverage provided.

HIPAA Acknowledgement

5. I authorize The Practice to release to staff, hospitals, health care service plans, Insurance companies, self-insurers or their representatives, specialty dentists involved in my care, any and all information, records, and other diagnostic material about my medical history, services rendered, or recommended treatment.

6. I acknowledge receipt of the Notice of Privacy Practices.

7. I authorize my protected health information with the following individuals who may be involved in my care and I understand I am responsible for notifying the Practice of any changes.

8.I authorize the following means of communication:

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.

Appointment Compliance Policy

Our goal is to provide quality dental care in a timely manner, ln order to do so we have had to implement an appointment cancellation policy. The policy enables us to utilize available appointments for our patients in need of medical care.

1. Confirmation Policy

All patients are to confirm their appointments within 48 hours of their appointment time. lf you do not confirm, you will be removed from the schedule in order to provide accessible care for other patients.

Cancellation/No Show Policy for Doctor Appointment

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. We will take into consideration in the event of an actual emergency, and no prior notice could be given. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to seemingly "full" appointment book

A "no show" is someone who misses an appointment without canceling it within a Z4-hour working day in advance. No-shows inconvenience those individuals who need access to dental care in a timely manner. After the third consecutive no-show you may be released from the practice.

To cancel an appointment, please call or text our office between the hours of 8:00 am-5:00 pm

at: (615) 325-9837.

1. Tardy for appointments

We understand that delays can happen, however, we must try to keep the other patients and doctors on time. lf you are running late, please notify the office right away

lf a patient is 15 minutes past their scheduled time, we may have to reschedule your appointment.

By Signing below you agree and understand the terms of this policy

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.