New Patient Registration Form

Patient Name

Name

Middle

Last Name

Preferred Name

Date

SS No.

Prev. Visit:

Email Address

Best time to call

Home Phone No.

Work Phone No.

Cell Phone No.

Ext

Fax No.

Other

Address 1

Address 2

City

State

Zip Code

Parent or Guardian name(s) (if patient is a minor - 18 & under)

Whom may we thank for referring you to our office?

Primary Dental Insurance Information

Name of Insured

Date of Birth

ID No.

Group No.

Insured's Address 1

Insured's Address 2

City

State

Zip

Insured's Employer Name

Employer Address

Address 1

Address 2

City

State

Zip

Insurance Plan Name

Insurance Address 1

Insurance Address 2

City

State

Zip

Policy for Filing Insurance

Our office has never been in network with any dental insurance providers, however as a courtesy we will file your claim. You will be responsible for any charges your insurance does not pay. If, for any reason your insurance company has not paid within 60 days of treatment, the balance will be your responsibility and you will need to re-file with your insurance company. The patient's estimated portion will be due at the time of service.

Payment Services

If you are a self-pay patient with no dental coverage, all financial responsibility must be paid at the time of service. In the event you do have insurance but are unable to provide us with the insurance card, you may be asked to pay in full at the time of service.

When insurance is provided we give an estimate to the best of our knowledge. In the event insurance does not pay in full you are responsible for the balance. All balances on accounts must be paid within 30 days. All delinquent accounts will be subject to being turned over to a collection agency.

By checking this box, I attest that the above information is correct to the best of my knowledge. I also understand that payment is due when services are rendered and that I will be responsible for any amount that insurance does not cover. This will serve as my electronic signature.

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION OR FINANCIAL INFORMATION

Patient's Name

Preferred Name

Date of Birth

PHI DISCLOSURE TO FAMILY MEMBERS

You may authorize us to contact a family member regarding your medical and/or financial matters. This is to acknowledge that you authorize Piedmont Dental to disclose your private health information to the following individuals.

Add Additional Family Member

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Piedmont Dental is committed to protecting your privacy. We will not release any information about you or your treatment without your consent. Only the people you list will be authorized to receive your information.

By checking this box, I acknowledge that a copy of this office's Notice of Privacy Practices is available to me upon request. This will serve as my electronic signature.

BROKEN APPOINTMENT AND CANCELLATION POLICY

We hold appointment times especially for you in good faith that you will be here. When patients do not show up or cancel at the last minute (regardless of the reason) we cannot fill the open slot. This results in nonproductive time with results in increased fees for everyone. We appreciate your understanding. There will be a $50 charge for ALL missed appointments and cancellations with less than 48 business hours prior to the scheduled appointment time.

By checking this box, I acknowledge that I have read the broken appointment policy. This will serve as my electronic signature.

HEALTH HISTORY

If Yes, who is your Physician?

If Yes, when?

If Yes, what?

If Yes, explain

If Yes, how often?

Please list any medications you are currently taking, one medication per line

Preferred Pharmacy and Address

Name and Phone Number of Emergency Contact

By checking this box, I acknowledge that I have provided the above information to the best of my knowledge. I also understand this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. This will serve as my electronic signature.

Patient's Signature

Date

Your information will be encrypted.