Patient Medical History
Page 1 of 7
Patient Medical History (con't.)
Please complete if patient has secondary dental insurance.
Emergency Contact/Referral Information
(If Under 18, Parent or Guardian Signature Required)
Page 2 of 7
Patient Dental History
Page 3 of 7
Acknowledgement of Receipt of Notice of Privacy Policies
Your Privacy Is Important to Us
I have read a copy of the Notice of Privacy Practices of Steven C. Bunting, D.D.S. & Associates, P.C.
I hereby authorize, as indicated by my signature below, Steven C. Bunting D.D.S. & Associates, P.C. to use
and to disclose my protected health information for my necessary clinical, financial, and insurance purpose,
as authorized in the Patient Consent form.
Please check your preferred means on communication:
Please list authorized persons with whom we may discuss your Protected Health Information (PHI
in addition to custodial parents and legal guardians:
Notice Of Privacy Policies Are Available To Review At Our Office Or Anytime Online.
For Office Use Only:We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,
but acknowledgment could not be obtained because:
Page 4 of 7
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THESE POLICIES ARE AVAILABLE TO REVIEW AT OUR OFFICE OR ANYTIME ONLINE.
Page 5 of 7
Notice of Privacy Practices (con't.)
Page 6 of 7
Thank you for choosing The Center for Aesthetic & Restorative Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
You can choose from:
Payment is required at the time services are rendered.
For patients with dental insurance, we are happy to submit claims to your insurance carrier electronically to ensure your reimbursement is sent to you quickly.
The office policy requires 48 hours notice to cancel an appointment to avoid a cancellation fee of $50.00.
There is a $30.00 charge for returned checks.
Any outstanding balance over 60 days will incur a 1.5% interest charge added monthly.
If you have any questions, please do not hesitate to ask. We are here to help you with your dental needs.
*subject to credit approval
Page 7 of 7