New Patient Registration

Responsible Party Information

(If different from Section 1)

Insurance Information

Emergency Information

Patient Dental History

Patient Medical History

Allergies

Drugs & Medications

Authorization

This office reserves the right to verify the credit status of potential patients prior to extending credit for treatment fees and may at the discretion of this office, use the services of one or more credit reporting services. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. And I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submission, whether manual or electronic.

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.

Thank you for filling out this form completely.

By signing, I agree that the information I have given today is correct to the best of my knowledge. I also understand that this information is held in the strictest confidence, as described in the Notice of Privacy Practices given to me. I recognize that it is my responsibility to inform this office of any changes in my medical status. I understand that when appropriate, credit bureau reports may be obtained. Furthermore, I authorize this staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

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.

HIPAA Compliance Patient Consent Form

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

The notice contains a patient's rights section describing your rights under the law You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or 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 this form, 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. singed by you. However, such a revocation will not be retroactive.

By signing this form. I understant 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.

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.