New Patient Registration Form
Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.
All of this information is completely confidential.
Responsible Party Information
Dental Insurance Information
INSURANCE INFORMATION & FINANCIAL GUIDELINES
It is our desire to make necessary treatment affordable to you. Please read all information and acknowledge by signing below.
As a courtesy to you, we will gladly file the patient's primary insurance claims for services rendered. Please furnish all information necessary to submit your claim. Please keep us informed of any changes to your policy.
It is imperative that the patient understands that we cannot make a totally accurate estimate of the insurance benefits. The insurance is a contract between you and your carrier. Any deductible, co-payment, or service not covered by your insurance carrier will be your responsibility and will be due when services are rendered. Rejection of the patients claim by their carrier does not relieve you of your financial obligation in our office. If your insurance denies our charges, or does not pay us in a timely manner, or if your account becomes delinquent, we reserve the right to refer your account to a collection agency and to be reported to the credit bureau.
I understand that the fee estimate listed for dental care can only be extended for a period of three months from the date of the patient examination. Any balances on your account must be paid in full before you will be seen again unless a payment arrangement has been made with billing personnel.
Returned checks will be subject to a Non-Sufficient fund fee of $35.
Rescheduling and Cancellation Guidelines
We respect your time and make every effort to remain on schedule. Please be patient if we are behind schedule, emergencies do occur. Your appointment time has been reserved especially for you. If you are late, we may not have the appropriate time to complete the procedure, therefore; we may need to reschedule your appointment to allow us the correct time to complete your dental treatment. If you feel you will not be able to keep your appointment, please give us a 24 hour notice. You will be subject to a $50.00 service charge without a 24-hour advance notice if 2 appointments are missed. If three appointments are missed, you will be dismissed from the practice for non- compliance. For appointment times over 1 hour, you will be subject to a $100 fee for every hour missed.
Agreement: I have read the above guidelines and understand my responsibility.
Dental History (New Patients Only)
I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.