WELCOME! On behalf of our staff, we look forward to meeting you. Dr. Karen Anne Lunsford ENCLOSURE : 4 PAGES OF REGISTRATION
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1 32 Willimansett Street - Rte Next to Big Y South Hadley, MA P / F WELCOME! Thank you for choosing our office for your dental services. We are located in the Westfield Bank building at the Big Y Plaza - 32 Willimansett Street, South Hadley, MA. For your convenience, we have attached the initial paperwork for you to complete prior to you visit. Please bring the completed paperwork with you, and any past dental records you may have. On behalf of our staff, we look forward to meeting you. Dr. Karen Anne Lunsford ENCLOSURE : 4 PAGES OF REGISTRATION
2 Patient Registration First Name: Last Name: Middle Initial: Preferred Name: Address: City,State,Zip: Home Phone: Work Phone: Ext: Cell: Birth : Sex: [ ] Male [ ] Female Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed *We use an automated reminder system to confirm appointments please check all that apply to allow our system to text or your appointment reminders. [ ] I can receive correspondence via- [ ] I can receive via-text messages Student Status: [ ] Full Time Student [ ] Part Time Student Preferred Pharmacy: _ Responsible Party [ ] Check here if same as above and skip to the next section [ ] Responsible party is also policy holder for patient Please check if patient is a minor or dependent. [ ] Minor [ ] Dependent First Name: Last Name: Middle Initial: Address: City, State, Zip: Home Phone: Work Phone: Ext: Cell: Primary Insurance Information Name of Policy Holder: Relationship to Policy Holder: [ ] Self [ ] Spouse [ ] Child [ ] Other Subscriber Id #: Insurance Company: Policy Holder s Birth : Employer: Secondary Insurance Information Name of Policy Holder: Relationship to Policy Holder: [ ] Self [ ] Spouse [ ] Child [ ] Other Subscriber Id #: Policy Holder s Birth : Insurance Company: Employer:
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4 Big Wide Smiles Payment in full is expected upon completion of each visit. For your convenience we accept cash, checks, and debit/atm cards and credit cards. We also participate with the Care Credit as an optional payment plan program. Minimum credit card transaction is $25. There is a return check fee of $30. As a service to you, our office will submit fees for service to your insurance company. The patient however is the primarily responsible for the account. Any co-payments/deductibles will be collected at the time services are rendered. When payment of insurance claims is assigned to us, that portion of the remaining balances, if any, is the patient s responsibility. If payment from the insurance company is not received within 90 days, it is the responsibility of the patient to pay in full. It also becomes the patient s responsibility to collect from the insurance company because it is the patient who has the contract with the insurance company, not Big Wide Smiles. In addition, this dental office is not responsible for knowing what specific procedures are covered by your insurance policy or the limits of your coverage. We require a 24 hour notice for cancellation of all scheduled appointments. There will be a $30 charge to your account for all failed appointments and canceled appointments without a prior 24 hour notice. Multiple failed appointments may result in discontinuation of our services. I authorize the release of medical information necessary to process claims for dental benefits. I authorize payment of benefits to Karen Anne Lunsford d/b/a Big Wide Smiles for services provided. I authorize dental treatment as necessary I have had the opportunity to review this office s Notice of Privacy Practices as required by HIPAA I agree to pay any balance I owe to Big Wide Smiles within 30 days of receiving an invoice for said balance. I agree that if I do not pay my balance within 30 days, finance charges will accrue on the unpaid balance at the rate of one and one half percent per month. I understand that legal action may be taken if I fail to fulfill this contract. Printed name-parent /Guardian, if patient is a minor or incompetent Signature
5 32 Willimansett Street - Rte Next to Big Y General Consent for Dental Treatment South Hadley, MA P / F DRUGS AND MEDICATIONS I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction.) Certain medications may cause drowsiness and it is advisable not to drive or operate hazardous equipment when using such drugs. I have informed the doctor of any known allergies. CHANGES IN TREATMENT PLAN I understand that during treatment it may be necessary to change or add procedures because of conditions discovered during treatment that are not evident during examination. I authorize my dentist to use professional judgement to provide appropriate care. Fillings I understand that a more extensive restoration than originally planned may be required due to additional conditions discovered during preparation. I understand that significant changes in response to temperature may occur after tooth restoration. I realize that the fillings are rarely permanent and will require periodic replacement. All dental and anesthetic procedures have associated risks. These may be, but are not limited to: - Drug reactions and side effects - Damage to adjacent teeth or fillings - Post-operative bleeding that might require additional treatment, and or post-operative infections - Delayed healing of an extraction site, (dry socket) necessitating additional care - Sinus involvement during removal of upper molars which may require additional treatment or surgical repair at a later date - Involvement of the nerves during removal of teeth resulting in temporary or possible permanent numbness or tingling of the lip, chin, tongue, or other areas - Bruising, swelling, sensitivity, or pain - Complications during treatment necessitating referral to a specialist _ I understand that dentistry is not an exact science and that no specific results can be assured or guaranteed. I acknowledge that no such guarantees have been made regarding the dental treatment I have authorized. I understand treatment plans and fees proposed are subject to modification depending upon unforeseen or undiagnosed conditions that may be recognized only during the course of treatment. I understand that any associated laboratory fees are my financial responsibility. I understand I will have the opportunity to have all my questions answered by my doctor and I certify that I understand English. My signature below signifies that I understand that if treatment and anesthesia that are proposed for me, there are known risks and complications. Patient (Legal Guardian's) Signature Doctor's Signature Dental Office - Witness' Signature
H&M Family Dentistry New Patient Information page
H&M Family Dentistry New Patient Information page Personal Information Patient Name Email Address City State Zip Home Phone Work Phone Cell Phone Date of Birth Social Security Number Sex M F Employer Occupation
First Middle Initial Last. SSN: Date of Birth . Address: City: State: Zip: Home Phone: Cell Phone: Sex: M F
Patient Information First Middle Initial Last SSN: Date of Birth Email Address: City: State: Zip: Home Phone: Cell Phone: Sex: M F Do you prefer appointment confirmations via (check one or both): TEXT
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You may refuse to sign this acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature: : Release of
CONSENT TO PROCEED. Patient Name: (Patient, legal guardian or authorized agent of patient)
CONSENT TO PROCEED I authorize Dr. Tyson Pickett and/or such associates or assistants as s/he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health
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Patient Registration
Patient Registration Patient s Name: Date of Birth: Mailing Address: Social Security #:_ Primary Phone #: Secondary Phone #: Employer: Work Phone: _ Emergency Contact: Emergency Contact Phone #: Person
Patient s Full Legal Name Patient Birth Date : Does Patient have a COURT APPOINTED Legal Guardian ( LG ) or ACTIVATED Power of Attorney (POA)?
Medical History Form ( Print Only Ink Only Circle Correct Answers ) ( Page 1) Patient s Full Legal Name Patient Birth Date : Does Patient have a COURT APPOINTED Legal Guardian ( LG ) or ACTIVATED Power
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PATIENT REGISTRATION
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Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
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Henritze Dental Group 4119 Brandon Ave. SW ROANOKE VA, 24018 (540) 776-6555 Email: brandon@henritzedental.com Website: www.henritzedental.com Steven N. Anama, DDS Patient Information Patient Name: Date:
bty DENTAL Group LLC. T: (907)
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WELCOME TO LEHIGH DENTAL
WELCOME TO LEHIGH DENTAL The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral health. Please fill out this form completely. The better we communicate,
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Morris Medical Center, P.A.
Thank you for choosing our practice to assist in your healthcare needs. We appreciate the confidence you and your personal physician have placed in us. Please read the following instructions and information
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Macon County Health Department Dental Clinic
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WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU
DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY:
Galaxy Smiles Children s Dentist and Braces 9575 W. Tropicana Ave. Suite # 5 Las Vegas, Nevada (702) CONSENT FOR TREATMENT
Galaxy Smiles Children s Dentist and Braces 9575 W. Tropicana Ave. Suite # 5 Las Vegas, Nevada 89147 (702) 633-8331 CONSENT FOR TREATMENT 1. I hereby authorize and direct Galaxy Smiles Children s Dentist
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