New Patient Registration

Patient's Name

Preferred Name

Title

Birth Date

SS No.

Previous Visit

Email address

Best time to call

Home Phone No.

Work Phone No.

Cell Phone No.

Fax

Address 1

Address 2

City

State

Zip

Whom may we thank for referring you to our practice?

In an emergency who should be notified?

Phone No.

Responsible Party Information

Employment Information

The following is for

the patient the person responsible for payment both not applicable

Employer Name

Phone No.

Employer Address 1

Employer Address 2

City

State

Zip

This section only needs to be completed if the patient is under 18 years old.

The following is for

the patient's spouse the person responsible for payment both neither-not applicable

Name

Preferred Name

Title

Birth Date

SS No.

Driver's License

Email address

Best time to call

Home Phone No.

Work Phone No.

Cell Phone No.

Ext.

Fax

Other

Address 1

Address 2

City

State

Zip

Primary Dental Insurance

Name of Insured

Insured's Birth Date

ID No.

Group No.

Insured's Address 1

Insured's Address 2

City

State

Zip

Insured's Employer Name

Employer Address 1

Employer Address 2

City

State

Zip

Patient's relationship to insured

Self Spouse Child Other

Insurance Plan Name

Insurance Address 1

Insurance Address 2

City

State

Zip

Insurance Company Phone Number

Insurance Authorization

By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Dental Information

How would you rate the condition of your mouth?

Excellent Good Fair Poor

Previous Dentist Name

Phone No.

Date of most recent dental exam and dental x-rays:

I routinely see my dentist every

3 mo. 4 mo. 6 mo. 12 mo. Not routinely

What is the reason for your dental appointment today?

Is there anything about the appearance of your smile that you would like to change?

If any of the checked boxes need further explanation, please describe

Consent for Services and Financial Policy

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.

HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,

Please check all that apply

You may contact me at my home telephone number

You may contact me on my work telephone number

You may contact me on my mobile telephone number

You may send me an email

Other

Please list authorized persons with whom we may discuss your Protected Health Informatio (PHI) in addition to custodial parents and legal guardians: (example: John Doe (212-555-1212)

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure 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.

Signature

Relation to Patient

Date

Your information will be encrypted.