New Patient Form

Please correct the errors described below.

PATIENT INFORMATION

(Street / Apartment # / City, State / Zip Code)

SPOUSE OR RESPONSIBLE PARTY INFORMATION

(Street / Apartment # / City, State / Zip Code)

EMPLOYMENT INFORMATION

(Street / Apartment # / City, State / Zip Code

DENTAL INSURANCE INFORMATION

CONSENT FOR SERVICES AND PRIVACY POLICY

I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor employs any such assistance as deemed appropriate.

I further authorize the release of any information, including the diagnosis, radiographs and records of any treatments or examinations rendered to my insurance company, consulting professionals or others who may request my records. I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins.

By signing below, I am testifying that the above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of the staff responsible for any errors omissions that I may have made in 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.

ACKNOWLEDGE OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I HAVE READ THE NOTICE OF PRIVACY PRACTICES FOR THE ABOVE NAMED PRACTICE.

MEDICAL HISTORY INFORMATION

DENTAL HISTORY INFORMATION

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.

Your message will be encrypted.