New Patient Forms

Please correct the errors described below.

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

DENTAL INSURANCE

MEDICAL INFORMATION

WOMEN ONLY Are you:

ALLERGIES

Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

Do you have, or have you had any of the following?

DENTAL INFORMATION

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this 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.

FINANCIAL AGREEMENT

We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health. The following is a statement of our Financial Policy, which we require that you read, agree to, and sign prior to any treatment. We are pleased to discuss our professional fees with you at any time. Your clear understanding of the Financial Policy Is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility upon arrival at your first appointment.

Adult patients are responsible for full payment at the time of service. The adult accompanying a minor, his/her parents or guardians are responsible for full payment at the time of service.

INSURANCE
We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company.
Please understand that we will provide an insurance estimate to you, however, It is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits will determine the amount paid. We will, of course, do all we can to make sure your estimate Is as accurate es possible. If payment Is not received or your claim is denied, you will be responsible for paying the full amount at that time. If you are paid by the Insurance company instead of our practice, you then become responsible for the total account balance and payment would be expected Immediately. We ask that you sign this and/or any other necessary documents that may be required by your insurance company.

DEDUCTIBLE/CO-PAYMENT

We ask that you pay the deductible and co-payment, which is the estimated amount, not covered by your insurance company, by cash, check, credit card, or outside financing at the time we provide the service to you.

DELINQUENT PAYMENTS

It is our policy to charge a finance fee for outstanding patient balances. In addition, all payments returned due to non-sufficient funds will be subject to a fee. In the event of default In payment reasonable collection agency fees equal to thirty percent of the delinquent balance and/or reasonable attorney fees, shall be added to the amount due on the account, plus applicable court costs. I give prior consent to receive calls and text messages from the creditor or its third-party debt collector, including calls and messages made by using an autodialer or pre-recorded message.

MISSED APPOINTMENTS

Unless canceled in advance, a fee may be charged for missed appointments. Please help us service you better by keeping scheduled appointments.

By entering your name below, I confirm that I have read, understand, and agree to the above terms and conditions.
I hereby authorize payments of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments In full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid, In whole or in part by my dental care payer.

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.

Privacy Policy

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my child's) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize the release of any information concerning my (or my child's) health care to another dentist. Unless you object, we will also share relevant information about your care with your family and friends who are helping you with your dental care. We may call, write or text to remind you of scheduled appointments or other office communication. Unless you tell us otherwise, we will call, write or text to address or phone numbers given. We will speak or leave messages at the numbers given.

I understand that I may withdraw or revoke my authorization at any time. I may revoke this authorization by notifying the practice in writing.

I understand that by signing this Consent form, I am giving my consent to disclose and discuss my protected health information to carry out treatment, payment activities, and health care operations.

The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of patient's dental needs. I also understand the use of anesthetic agents embodies a certain risk. I have read, understand and agree to the above terms and conditions.

At Saratoga Family Dental We take the privacy of your health and dental information seriously. We will not release a patient's health or dental information outside of the allowed exceptions spelled out in our Notice of Privacy Practices without your verval or written permission.

This form gives you the opportunity to tell us who we can speak to regarding your health and dental information. You are not required to list anyone and you can change who we are permitted to speak to at any time by completing a new form.

I authorize Saratoga Family Dental doctor and/or staff to speak to the individuals listed below regarding my health, dental needs, and billing information. I understand that I can revoke this authorization at any time by completing a new form.

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.

Your information will be encrypted.

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