New Patient Regstration – Comprehensive Contemporary Dentistry

Welcome to our Practice

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Appointment Date

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Chart#

FOR OFFICE USE ONLY

Patient Name:*

Last

First Name*

First

MI*

Preferred Name*

Preferred Name

Title:

Mr/Ms/Mrs/etc

Gender:

Male

Female

Non Binary

Family Status:

Married

Single

Child

Other

Birth Date:

SS#:

Prev. Visit:

Email Address:

Best time to call:

Phone:

Home

Mobile

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Work

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Ext

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Fax

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Other

Address:

Address 1

Address:

Address 2

City

State

Zip Code

Whom may we thank for referring you to our practice?

In an emergency who should be notified? Please enter Name and Phone number below:*

Employment Information

The following is for:

the patient

the person responsible for payment

both

not applicable

Employer Name:

Phone:

Employer Address:

Address 1

Address:

Address 2

City

State

Zip Code

Responsible Party Information:

This only needs to be filled out if the insurance subscriber is other than patient, or you are the parent/guardian of the patient

The following is for:

the patient's spouse

the person responsible for payment

both

neither-not applicable

Name:*

Last

First Name*

First

MI*

Preferred Name*

Preferred Name

Title:

Mr/Ms/Mrs/etc

Gender:

Male

Female

Non Binary

Family Status:

Married

Single

Child

Other

Birth Date:

SS#:

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DL#:

Email Address:

Best time to call:

Phone:

Home

Mobile

Hidden

Work

Hidden

Ext

Hidden

Fax

Hidden

Other

Address:

Address 1

Address:

Address 2

City

State

Zip Code

Primary Dental Insurance:

Name of Policy Holder:

Last

First Name

First

Policy Holder Birth Date:

ID #:

Group #:

Policy Holder Address:

Address 1

Address:

Address 2

City

State

Zip Code

Policy Holder Employer Name:

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Employer Address:

Address 1

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Address:

Address 2

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City

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State

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Zip Code

Patient's relationship to insured:

Self

Spouse

Child

Other

Insurance Plan Name:

Insurance Plan Address:

Address 1

Address:

Address 2

City

State

Zip Code

Insurance Plan Phone Number:

Do you have a secondary dental insurance,( if yes, please provide information to the reception staff)

Yes

Primary and Secondary Insurance Authorization:

confirmationCheckbox

By checking this box,
I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.

Consent for Services and Financial Policy

I hereby authorize H. Brandt Foster, DDS or other persons he may appoint, to perform or assist in the performance of the dental treatment or procedures which, upon discussion, I have accepted in the treatment plan. If any unforeseen condition arises in the course of these designated procedures calling, in their judgement, for procedures in addition to or different from those now contemplated, I further request and authorize what he/she deems advisable.

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any 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.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. 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.

confirmationCheckbox*

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the AdministrationForm.

Cancellation Policy

We require a call back for appointment reminders left on your voicemail, or reply to emails in regards to your scheduled appointments.

Please be advised that we require at least 2 business days notice be given if you are cancelling or rescheduling an appointment. If 2 business days are not given, you may be subject to a $100 per hour charge and/ or be required to be placed on a stand by status

confirmationCheckbox*

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the cancellation policy.

HIPAA

I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed.

I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

Whom may we share your personal and financial information with? Please list name and relationship to patient.

confirmationCheckbox*

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.

Consent for Internet Communications

1. I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

2. I understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf.

I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

confirmationCheckbox*

I have read the information above regarding the secured uploading of patient information to secured web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site. This will serve as my electronic signature.

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Response Date