New Patient Information

Patient's Name

Today's Date

Birth Date

SS No.

Prev. Visit

Email address

Best time to call

Phone No.

Work No.

Cell No.

Fax

Address 1

Address 2

City

State

Zip Code

Employment Information

The Following is for

Patient Person Responsible for Payment Both Not Applicable

Employer Name

Phone No.

Employer Address 1

Employer Address 2

City

State

Zip

Who may we thank for referring you to our practice?

In an emergency who should be notified?

Name

Relationship to Patient

Phone No.

Responsible Party Information

This ONLY needs to be filled out if the insurance subscriber is NOT the patient, OR if you are the parent? guardian of the patient.

The Following is for

Patient's Spouse Person Responsible for Payment Both Neither Not Applicable

Name

Preferred Name

Birth Date

SS No.

DL No.

Email address

Best Time To Call

Home Phone No.

Work Phone No.

Cell Phone No.

Fax Phone No.

Address 1

Address 2

City

State

Zip Code

PRIMARY DENTAL INSURANCE

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SECONDARY INSURANCE

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DENTAL INFORMATION

How would you rate the condition of your mouth?

Excellent Good Fair Poor

Previous Dentist Name & Phone No.

I routinely see my dentist every

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

What is your immediate concern?

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

Office Policy

FINANCIAL POLICY

Basically, our policy is to deliver the most comprehensive dental care and as cost-effective as possible. We will strive to be as accurate as possible in our estimate of what your treatment will cost before we begin. Therefore, your co-payments and deductibles will be due at the time of service. To assist you, we accept cash, checks, all major credit cards and CareCredit.

There will be times when the treatments is more extensive than originally estimated and if this occurs, Dr. Godfroy will inform you of the change as well as explain the need for it and your estimate will be adjusted accordingly.

INSURANCE

As courtesy to our patients, we will be happy to file your insurance and accept assignment. However, to avoid misunderstanding, please read and understand the following:

It is your responsibly to be fully aware and knowledgeable about our insurance coverage and inform us of any changes.
We ask that you view your insurance realistically. It is an insurance plan that either you or your employer has chosen and some services may not be covered.
Any balance left unpaid by insurance is your responsibility. This balance is to be paid in full when you receive a statement from us.
When your treatment is for basic and / major services, a copayment or deductible will be due at the first visit.

APPOINTMENTS

We provide our patients with scheduled appointment times. By keeping your scheduled appointment. you allow us to make your visit with us comfortable and pleasant as well as be efficient with your time. Missed or changed appointments at the last minute, are then unavailable to other patients who need them. Therefore, we reserve the right to charge $50.00 for a broke appointment when a 48 hour notice is not given.

I have read and I understand the above OFFICE POLICY.

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

Date

HIPAA

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature and date.

You have the right to restrict how your protected health information is used and disclosed for treatment and payment of healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

I understand that:

Protected health information may be disclosed or used for treatment, payment or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

If YES, please name the person(s) allowed:

Signature

Date

PATIENT MEDICAL HISTORY

Patient Name

Date

Your Primary Care Physician

Phone No.

Address

City

State

Zip Code

List of Medications

Other

PLEASE MARK ANY OF THE FOLLOWING TO INDICATE YES IN RESPOSE TO THE QESTION

Are you currently under the care of physician due to a specific condition?

Have you been hospitalized within the last 5 years due to a surgery or illness?

Are you currently taking any prescription or non-prescription medications?

Do you use tobacco (smoking or chewing)?

Do you use alcohol?

Do you use recreational drugs?

Do you have any joint replacements?

Do you have any other conditions, diseases, etc. not listed above that we should be aware of ?

If any of the previous questions are marked, Please explain and indicate how much and how frequent

Notes on Above

WOMEN ONLY: Are you...

Pregnant or think you are?

Nursing?

Taking Birth Control Pills?

If yes, when is the due date?

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health or medications, I will inform the office at my next dental appointment without fail.

AUTHORIZATION

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and or inaccurate has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and or healthcare practitioners. I authorize the payment from my insurance carrier to be paid directly to the dentist or dental practice and to be applied to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (If any.)

Signature of Patient, Parent or Guardian

Relationship to Patient

Date

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