New Patient Form

Please correct the errors described below.

Patient Information

List your First Name, Middle Initial, and Last Name

Family Information

Please list the names and birthdates of your immediate family members.

Insurance Information

Dental History

Leave blank if you are unsure
Leave blank if you are unsure

Medical History

Leave blank if you are unsure
List any medications you are currently taking (include over-the-counter pain reliever or allergy medication)

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Assignment and Release

I, the undersigned, have insurance with the company(ies) listed above and assign directly to Dr. Stephanie Scheich or Dr. Jeff Scheich all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of confirmation on all of my insurance submissions whether manual or electronic. I have also read and understand this office's HIPAA policies and guidelines.

Minor/Child Consent

I, being the parent or guardian of minor/child (named above) do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.

Financial Agreement

I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance.

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