New Patient Paperwork

Please correct the errors described below.

Patient Information

Responsible Party

Insurance Information

If yes, complete the following.

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.

Medical Information

Medical Conditions

Emergency Contact

Person to be contacted in case of an emergency

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.

Dental History

By signing below, I certify that the above information is complete/accurate.

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.

Office Policy Notice

Dear Patients,

Appointments you schedule at our office is a time reserved just for you. Any changes in these appointments affect many patients.

We certainly understand circumstances arise that prevent patients from keeping appointments. If you find it impossible to keep an appointment, we require you to give us at least 48 hour notice prior to your appointed time. We will try to give you a courtesy call but you are ultimately responsible for your appointments.

If you miss, cancel or change your appointment with less than 48 hour notice, you will be charged a cancellation fee of $45.00. This policy is in place out of respect for your dental team and our clients. Cancellations with less than 48 hour notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot.

Thank you in advance for your cooperation.

Sincerely,

Dr. Rongcal & Staff

Please sign below that you read and agree to these terms.

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.

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of D.B.A. Maul Island Cozy Dental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

D.B.A. Maul Island Cozy Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Health Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)


OFFICIAL USE ONLY BELOW THIS LINE

Your information will be encrypted.

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