New Patient Forms

S. Lee Falkenheiner, DDS, PLLC - Family and Cosmetic Dentistry

Please correct the errors described below.

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help.

Patient Information (CONFIDENTIAL)

Responsible Party

Insurance Information

IF YES, COMPLETE THE FOLLOWING:

Patient Medical History

7. Do you have or have you had any of the following?

8. Are you allergic to or have you had any reactions to the following?

10. Women Only

Patient Dental History

7. Have you ever experienced any of the following problems in your jaw?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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

I understand that, under the Health, Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used, but is not mandatory for me to sign in order to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare
    providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers
  • Conduct normal healthcare operations such as quality assessments and physician certifications

I have been informed by you and your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given a copy of your Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Digital Photography

Dr. Falkenheiner may take digital photographs to better explain certain aspects of your existing dental health or planned treatment to you. We request your permission to show these photographs to better explain treatment options to other patients (as you will be shown photos for the same reason). Your identity will not be shared.


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.

Written Financial Policy

Thank you for choosing Dr. S. Lee Falkenheiner. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:

You can choose from:

  • Cash, Check, Visa or Mastercard
  • NO INTEREST(1) Payment Plans(2) from CareCredit
    • Allow you to pay over time with NO INTEREST(1)
    • Convenient, low monthly payment plans(2) also available
    • No annual fees or pre-payment penalties

Please note:

Dr. S. Lee Falkenheiner requires full payment at the completion of your treatment.

We accept payment in halves. For plans requiring more than 2 appointments, alternative payment arrangements may be provided.

We also offer in-house financing for up to 3 months. No interest

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.(3)

A fee of $25 is charged for patients who miss or cancel more than 3 times in a calendar year without 24-hour notice.

NSF fee is $30 for returned checks.

For patients who receive direct payment from your insurance company, you are required to leave a check in the amount of the insurance payment. The check will be returned to you when the insurance check is received.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

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.

(1) If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.

(2) Subject to credit approval

(3) However if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

Your information will be encrypted.

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