New Patient

Chart #: 
 FOR OFFICE USE ONLY 

Patient Information

  Last First MI (Preferred Name)    
  Street Apartment #
 
  City State Zip Code

Health Information

Date of Last Dental Visit: Reason for this visit:
Have you ever had any of the following? Please check those that apply:
 
 
 
Have you ever had any complications following dental treatment? Yes   No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years? Yes   No
If yes, please explain:
Are you now under the care of a physician? Yes   No
If yes, please explain:
Name of Physician: Phone:
Are you currently taking any medications? Yes   No
If yes, please list:
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Date:
Signature of patient, parent or guardian    

Referral Information

Whom may we thank for referring you to our practice?
Name of person or office referring you to our practice:

Responsible Party for Payment Information

(if you then just put self)
The following is for:
Name :
Social Security #: Birth Date:
Phone(Home): (Work): Ext: Best time to call:
  Street Apartment #
 
  City State Zip Code

*** PATIENT MUST FILL OUT THIS SECTION. ***

In Case Of Emergency Contact

Name: Address:
Phone: Relationship to patient:

Consent for Services

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my needs.

Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

I agree to the use of anesthetics, sedatives and other medication as necessary. I full understand that using anesthetic agents embodies certain risks. I understand that I can ask complete recital of any possible complications.

I give consent to the doctor’s or staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for any co-payment of all dental services not covered by the insurance. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Date: Relationship to Patient:
Signature of patient, parent or guardian
Date: Relationship to Patient:
Signature of guarantor of payment/responsible party