Patient Registration Form

PORTLAND DENTAL CENTER

Please correct the errors described below.

Responsible Party ( if someone other than the patient ):

Patient Information

Section 2

Section 3

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.

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.

Notice of Privacy Practices

I understand that the new Privacy Act effective April 14, 2013, affords me rights as a patient of this practice. This office will have copies of its "Notice of Privacy Practices" available in the reception area of the practice for my review. I am aware I may request a copy of these notices at any time. By my signature and date below, I acknowledge that I have been informed of this.

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.

Please identify by name and relationship to you those whom we are permitted to share information:

Add another authorized person

Emergency Contact

Add another contact person

Federal Truth in Lending Disclosure Statement for Professional Services Rendered

I understand and agree that Dental and Accident insurance policies are an arrangement between the employer, employee and insurance carrier. I also understand that it is my responsibility to provide correct information pertaining to my dental insurance. When possible, this office will prepare insurance forms (pertaining to dental) in an effort to collect payment from the insurance company. I authorize and request my insurance company to pay directly to the dentist and will be credited to my account. However, I clearly understand and agree that all services rendered to me or any family member is charged directly to me and I am personally responsible for payment. I understand my dental insurance carrier may pay less than the actual bill for service. If for some reason(s) the insurance benefits are not received, the responsible party or legal guardian will assume the unpaid balance. All fees will revert to the rates that are used in this office in the event a dental plan is terminated.

In the event collection steps becomes necessary for this account, Attorney's Fees, Collection Fees, and Court Cost will be charged to the responsible party or legal guardian.

I consent to treatment for myself and/or on behalf the minor for which this information pertains. I give permission for the doctor to examine, diagnose and initiate as deemed appropriate. I further attest that I am the Parent or Legal Guardian of the minor or have the authority to authorize care and treatment.

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.

Your information will be encrypted.

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