Patient Health History

Patient Name

Birthdate

PERSONAL INFORMATION

If yes

Are you taking any of the following medications?

If yes

Women: Are you....

Pregnant / Trying to get Pregnant

Nursing?

Taking oral contraceptives?

PLEASE LIST MEDICATIONS YOU ARE CURRENTLY TAKING AND INCLUDE WHAT THEY ARE FOR.

Please list allergies not mentioned above

If yes, Please specify

Please specify type, date and area's treated.

If yes, Please specify

Please List Surgeries Not Mentioned Above Including Dates.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's ) health. It is my responsibility to inform the dental office of any changes in medical status.

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 of Patient, Parent or Guardian

Date

PATIENT INFORMATION

Name

Date of Birth

Name of Guardian / Parent (if a child)

Phone No.

Cell Phone No.

Address

City

State

Zip

Email address

If yes, Address

City

State

Zip

Person Responsible for billing

Emergency Contact

Phone No.

Nearest relative

Phone No.

Insurance Company

Communication Preferences:

At this time we are offering communication through telephone calls. As we expand into other forms of communications, which would you prefer?

Phone Calls

Text

Please check which phone line

Home phone

Cell phone

Work phone

Payment is expected at the time of service unless prior arrangements have been made with our front business office. As a courtesy to you, we will file most insurances. However, if the 60 days your insurance has not paid you will be expected to pay your balance in full. If account is placed with collection agency, all fees incurred for the purpose of collecting the outstanding balance will be added to the account.

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.

Patient / Parent Signature

Date

Notice of Privacy Practices Acknowledgement

I understand that under the health Insurance Portability and Accountability Act (HIPAA; "Act") of 1996, I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

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

I have read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. 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 anytime to obtain a current copy of the Notice of Privacy Practices.

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.

Patient Name or Legal Guardian

Date

PRACTICE USE ONLY

I attempted to obtain the patient's signature in acknowledgment of the Notice of Privacy Practices Acknowledgment but was unable to do so as documented below

Appointment Cancellation Agreement

Kelly McKnight Dentistry appreciates the confidence you have shown in choosing us to provide for your dental care needs. It is important for all patients to keep their dental appointments, and understand that missed appointments result in lost time that could have been used to provide care to another patient.

Rescheduling Appointments

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we require all patients to call at least 24 hours in advanced to cancel or reschedule any appointments.

Missed Appointments.

If you miss or cancel appointments with less than 24 hours notice, a missed appointment note will be recorded in your account along with a $25.00 missed appointment fee.

I understand the dental appointment agreement and agree to follow the terms of the pravicy

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.

Patient Signature

Date

As a courtesy to our patients, we submit your treatment to your insurance company. We verify your insurance and provide you with an estimate of what your insurance company is expected to cover. We will collect the difference at the time of service. Reasonable efforts will be made to get your claims processed, however, after these efforts have been exhausted you will be required to pay your account balance in full. We ask that you be mindful that this is a courtesy provided to you as our patient. Ultimately you are responsible for your account balance.

Policy Holder

Policy Holders Date of Birth

Insurance Company

ID No. or SS No.

Group No.

Employer or Individual Plan

Telephone No. (Located on back of card)

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.

Patient's Signature

Date

Your information will be encrypted.