Multiple New Patient Form

Contact Information

Emergency Contact

Financial Responsibility

Please indicate who will be financially responsible for this account.

Dental Information

Please indicate who is experiencing these symptoms.

Medical Information

Please indicate who has experienced or is experiencing any of the following.

Disclaimer and signature

BROKEN APPOINTMENT POLICIES:

A charge of $30.00 is made for hygiene appointments that are missed, cancelled or rescheduled when less than 24 hours’ notice is given. The charge will be $50.00 for a treatment appointment.

FINANCIAL POLICIES

Payment for professional services is due at the time dental treatment is provided. If your insurance has copays and/or a deductible, the estimated amount will be collected at the time of service. If you do not have dental insurance, the full amount will be collected at the time of service. Past due accounts are subject to $5.00 monthly billing fees until the account is paid in full. Delinquent accounts are also subject to collection action after four failed attempts to collect the debt. In the event that your family account is submitted to our collection agency, the patient doctor relationship will be terminated. We will transfer any records upon your request.

Please read the above and understand that the information provided in this form is accurate. A truthful health history will help ensure the best possible dental treatment. The information provided here will be used by the doctor and patient to inform any further discussion of the patient's health prior to or during an appointment. By signing below, you also acknowledge that you will not hold the dentist, the dental practice or any other member of the practice staff responsible for any action or lack of action because of errors or omissions that may have been made during the completion of this 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.

Dental Insurance Information

Patient Information

Subscriber Information

Dental Insurance

Disclaimer and signature

FINANCIAL POLICIES:

Payment for professional services is due at the time dental treatment is provided. If your insurance has copays and/or a deductible, the estimated amount will be collected at the time of service. If you do not have dental insurance, the full amount will be collected at the time of service. Past due accounts are subject to $5.00 monthly billing fees until the account is paid in full. Delinquent accounts are also subject to collection action after four failed attempts to collect the debt. In the event that your family account is submitted to our collection agency, the patient doctor relationship will be terminated. We will transfer any records upon your request.

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.