Patient Information Form

Patient's Name

Date of Birth

Street Address

City

State

Zip

Home Phone No.

Work Phone No.

Cell Phone No.

Email address

Social Security No.

Parents' Name (this form is for a child)

Spouse Name (If married)

Employer

Occupation

Emergency Contact Name

Relationship

Emergency Contact No.

How did you hear about us?

DENTAL INSURANCE INFORMATION

Insurance Company Name

Group Number

Address

Phone Number

Employer

Subscriber's ID

Subscriber's Name

Patient's Date of Birth

Subscriber's Date of Birth

Relationship

OUR OFFICE IS NOT IN-NETWORK WITH ANY INSURANCE COMPANY

MEDICAL HISTORY

Patient's Name

Birthdate

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

If yes

If yes, How much?

Women: Are you

If yes, Please explain

Have you ever had any serious illness not listed above?

Comments

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 Acknowledgement of Receipt of Notice of Privacy Practices

Hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:

How this office will use and disclose my protected health information.
My privacy rights with regard to my protected health information.
This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of fany revised Notice of Privacy Practices upon request.

I also understand that if I have any questions or complaints, I may contact

You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S. Department of Health and Human Services.

Patient or Parent Representative

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.

Name / Signature

Relationship to Patient

Date

Written Financial Policy

Thank you for trusting the team at Lisa A Slaughter, DMD with your oral care. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of this mission is making the cost of care as easy and manageable for our patients as possible by offering several

Payment options.

Our office accepts:
Personal Checks, Cash, Visa, Mastercard, Discover, American Express, and Care Credit.

Please Note: Payment is expected at the time of service. When a minor is seen at our office, payment is the responsibility of the adult present at the time of treatment unless arrangements are made prior to the appointment.
If a patient has a balance over 90 days past due and has not responded to mailed statements, we will attempt to contact that patient by phone. If we hear no response from the patient, we will forward your account to collections and their fee of 32% will be added to the balance overdue.
Our office charges $45.00 for returned checks. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

I have read the above statement and agree to the terms:

Patient/Parent/Guardian Signature

Date

Your information will be encrypted.

Patient Information Form

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Patient or Parent Representative

Written Financial Policy

DR. LISA SLAUGHTER, DMD

General Dentistry