Patient Information Form

Please correct the errors described below.

Patient Name

Address

Name of Responsible Party:

Address: (if different from patient)

Phone:

Address

Dental Benefit Plan Information

Address:

Address:

Medical Plan Information

Address:

Whom may we thank for referring you?

Please list other members of your immediate family who are patients in our practice

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Patient Responsibilities: We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.

Payment: Payment is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. We accept the following forms of payment Cash, Credit, Check.

*Please note: If you select to apply for third-party financing, administered through our practice, we are required by law to provide you with a Credit for Dental Service Notice.

Dental Benefit Plans: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.

a contracted provider with your dental benefit plan.

If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If the customer of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.

If we are not a contracted provider with your dental benefit plan, it is the patient’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from out-of-network providers. If your plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if the amount is different than our estimated patient portion of the bill. If you choose to not “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your dental benefit plan and will be responsible for payment to our practice before or at the time of service.

Scheduling of Appointments: We reserve the doctor and hygienist’s time on the schedule for each patient procedure and are diligent about being on-time. Because of this courtesy, when a patient cancels an appointment, it impacts the overall quality of service we are able to provide. To maintain the utmost service and care, we do require 48-hours notice to reschedule an appointment. With less than 48-hours notice, a fee of $50 or deposit to reserve the appointment time again may be required. To serve all of our patients in a timely manner, we may need to reschedule an appointment if a patient is fifteen minutes late or more arriving to our practice. To reschedule and appointment due to late arrival, a fee of $50 or deposit to reserve the appointment time again may be required.

Authorizations: I understand that the information I have given today is correct to the best of my knowledge. I authorize this dental team to perform any necessary dental services that I may need and have consented to during diagnosis and treatment.

I have read the above and agree to the financial and scheduling terms.

I authorize the release of information necessary to process my dental benefit claims. I hereby authorize payment directly to this doctor otherwise payable to me.

I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may regarding this Notice.

I hereby acknowledge that a copy of this practice’s Dental Materials Fact Sheet has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Fact Sheet.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Confidential Health History Form

Patient Name:

I. Select the appropriate answer (leave blank if you do not understand the question)

II. Have you experienced any of the following? (Please select Yes or No for each)

III. Have you hod or do you have any of the following? (Please select Yes or No for each)

This information will not be released unless specifically authorized by patient.

IV. Are you allergic to or have you had a reaction to any of the following? (Please select Yes or No for each)

V. Are you taking or have you taken any of the following in the last three months? (Please select Yes or Na Far each)

Please list all medications you are currently taking

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VI. Women only (Please select Yes or No For each)

VII. All patients (Please select Yes or No For each)

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/ or medication. Further, I will not hold my dentist, or any other member of his/ her staff, responsible for any errors or omissions that I may have made in the completion of this form.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Medical updates

I have reviewed my Health History and confirm that it accurately slates past and present conditions.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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Dental Health History Form

Patient Name

Address:

FAMILY AND FRIENDS AUTHORIZATION

In order to discuss or disclose any dental information to your family or friends we must have a signed consent on file allowing Quijano Dental Corporation to share information about your care at our office with your family members or friends. Please list the names of those you would like to involve in your dental care. This information can be changed or revoked at anytime with your permission.

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I authorize Quijano Dental Corporation to share information related to my health status to the individual(s) listed above.

I understand this might include such information as: diagnosis. prognosis and treatment plans, medications, test results, appointment reminders, dental billing, insurance, and any other dental information relevant to my care.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PHONE & TEXT MESSAGE AUTHORIZATION

From time-to-time in caring for our patients, it may be necessary or desirable to contact patients by phone. When you are not available for us to speak to directly, we like to leave messages or send text messages when possible.

In order to protect your privacy:

  • We will not discuss any dental information with anyone except the patient, legal guardian, or person(s) you have listed on our Family and Friends Authorization Form
  • We will not leave any dental information on an answering machine.
  • We will not leave any dental information on a voice mail system.
  • We will attempt to, as a courtesy. leave a reminder message regarding an appointment.

Unless:

We have your written permission to leave detailed messages for you. If you would like to allow detailed voice messages regarding your dental care. please list those phone numbers. check and sign the appropriate section below.

If you do not want to allow detailed voice messages regarding your dental care, please check and sign the appropriate section below.

I authorize Quijano Dental Corporation to leave phone messages regarding my dental care at the following phone numbers:

I wish to be contacted personally. I do not authorize detailed messages regarding my dental care be left on an answering machine. voice mail, or with anyone else.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

For Office Use Only

Your information will be encrypted.

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