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...

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.

Special Authorization

consent for the Practice to use my (check all that apply):

From my record or information that I provided in a testimonial, written document, or other format for the specific purpose of (check all that apply)

The name of the individual or the name of the person authorized to make the requested disclosure stated above.

I have been informed that I am not required to sign this consent.
I understand I am not financially compensated for this authorization.
This consent may be revoked by written notice delivered to Practice Name within 30 days of signature.

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.

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.

Notice of Privacy Practices

I understand that the 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 practice for my review. I am aware I may request a copy of these at any time. By my signature and data below, I acknowledge that I have been informed of this.

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 Identify by name and relationship to you those whom we are permitted to share information

Please List Emergency Contacts