PATIENT REGISTRATION
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- Jemima Hubbard
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1 PATIENT REGISTRATION
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3 DEERBROOK FAMILY Dentistry Hwy 59 N, Suite 300, Humble, TX Fax: General Consent I,, consent to be a patient at the above named office and agree to a radiographic and clinical examination. I also understand and consent to the following: 1. During the course of treatment, I can submit to procedures in all phases of dentistry including periodontics (gums treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), dental implant, restorative dentistry, temporomandibular disorder treatment, treatment of sleep apnea, oral pathology, pediatric dentistry and the x-ray. 2. I am going to provide a thorough and complete medical history, provide a full list of my medications with dose and consent to my dentist to communicate with my other doctors to ask about any aspect of my medical history. 3. No guarantees can be made about the results of the treatment, the restoration of the longevity, or prognosis. I understand that any branch of medicine, including dentistry can produce unexpected results. 4. I will pay in full any cost of treatment or insurance copayments according to the office policy. I understand that even if an insurance pre-estimate is given or a procedure has been preapproved, I am responsible for any cost that my insurance does not cover. 5. My treatment plan may change at any time and I will make my best effort to approach my dental care with optimism and open communication with my dentist, dental hygienist, and the staff of the office. 6. I am welcome to ask about any aspects of my dental care and request information if I am confused or need more information. I am responsible to clarify any aspect of my treatment that I am unsure about. Patient Name (Please Print) Signature of the patient, legal guardian Date Or Authorized Representative The name and the relationship to the patient
4 DEERBROOK FAMILY Dentistry Hwy 59 N, Suite 300, Humble, TX Fax: Office Policy Payment for Services: Payment is expected at the time of your services. We accept cash, Visa, MasterCard, American Express, Discover, CareCredit and Citi Healthcard. We do not accept personal checks. Any unpaid balance over 90 days will be considered delinquent and turned over to a collection agency. Fees may apply. Dental Insurance: We will be happy to submit an insurance claim for you as a courtesy. It is your responsibility to inform us of any changes in your insurance carrier or policy. If your insurance company denies your claim, we expect payment of the full balance within 10 days of the notice you receive from your insurance company. Professional services are rendered to a person, not to the insurance company. Our treatment is based on the dental need of the patient, not the insurance company benefits. We cannot render services to a patient on the assumption that the charges will be paid by the insurance company, nor can we know every service not covered by your insurance company. We will help in any way possible to file your claim or handle any insurance queries you may have. It is your responsibility to be involved with your insurance company. The patient is responsible to the doctor and the insurance company is responsible to the patient. Consent: I authorize release of any information and/or x-rays relating to my dental treatment to the insurance company, attorney or collection agency in collecting the full cost of the services provided. I authorize release of any information and/or x-rays to offices where I have been referred. Appointments: When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please notify us at least 48 hours in advance. This courtesy makes it possible to give your reserved room to another patient who would like it. There is a $25 charge for not showing up for scheduled appointments. Repeated cancellations or missed appointments will result in the loss of future appointment privileges. Saturday Appointments: An appointment reservation deposit of $200, regardless of insurance benefits, is required when scheduling an appointment on a Saturday. This deposit is non-refundable if the appointment is missed. By signing below, you have read and agree to our Office Policy. Patient s name (please print) Signature of patient, legal guardian Date or authorized representative Name and relation to patient
5 ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES Deerbrook Family Dentistry Hwy 59 N Suite 300 Acknowledgment I,, hereby acknowledge that I have received and reviewed a copy of Deerbrook Family Dentistry's HIPAA Notice of Privacy Practices. I understand that Deerbrook Family Dentistry's HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of Deerbrook Family Dentistry's revised HIPAA Notice of Privacy Practices upon request. I understand that, if I have questions about Deerbrook Family Dentistry's HIPAA Notice of Privacy Practices, I may contact Crystal Pardini at I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that Deerbrook Family Dentistry will not refuse treatment to me if I refuse to sign this Acknowledgement. I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding Deerbrook Family Dentistry's privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Crystal, noted above, for assistance. Patient Signature Date Signature of Personal Representative Print Name of Personal Representative Relationship of Personal Representative to Patient FOR OFFICE USE ONLY Deerbrook Family Dentistry made a good-faith effort to obtain Acknowledgement, from the patient noted above, of receipt of its HIPAA Notice of Privacy Practices. In spite of these efforts, Deerbrook Family Dentistry was unable to obtain a signed Acknowledgement for the following reason(s): Refusal to sign Acknowledgement on, 20. Communications barriers prohibited us from obtaining a signed Acknowledgement. An emergency situation prohibited us from obtaining a signed Acknowledgement. Other (Describe): Date Received By Patient ID
6 Name: Date: Please tell us how you learned about our practice. (Select ALL that apply) Friend/Family Staff member Other dentist/doctor Name: Name: Name: Our website Internet search Insurance Company Search Engine: Insurance Company: Office Sign/Window Referral Card Direct Mail Post Card Smile Savings Program Brochure Drive by Other:
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PATIENT REGISTRATION (Please print) Patient s Legal Name: Last First Middle Preferred Name: Street Address: City St Zip Phone Numbers: Home Cell Work Email address: Which method is best to confirm appointments
Prince Family Dentistry
Prince Family Dentistry 702-240-0202 830 S. Durango Dr., Ste. 104 Las Vegas, NV 89145 PATIENT INFORMATION Last Name First Name MI Preferred Name Birthdate {Male { Female SS# {Minor { Single { Married {
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
205-661-2201 3713 Mary Taylor Road Birmingham, AL 35235 Date: PLEASE FILL IN ALL INFORMATION COMPLETELY NAME ADDRESS CITY STATE ZIP HOME PHONE # CELL # WORK # EMAIL DATE OF BIRTH: SEX SELECT ONE: SINGLE
CHILDREN S DENTISTRY OF RANCHO CUCAMONGA Welcome to our practice!
CHILDREN S DENTISTRY OF RANCHO CUCAMONGA Welcome to our practice! We strive to make each of your child s visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep
Welcome to Our Office - Tell Us About Yourself
General, Cosmetic & Implant Dentistry Welcome to Our Office - Tell Us About Yourself Name: Last First MI Title Address: City: State: Zip: SSN: Male Female DOB: Home Phone: Work Phone: Cell Phone: E-Mail:
Patient Guide to Billing and Insurance
Patient Guide to Billing and Insurance Patient Account Payment Policies December 2017 Lexington Clinic Central Business Office Payment Policies Customer service...2 Check-in...2 Plan participation, network
Our philosophy of care governs everything we do for you. It consists of the following key elements:
Welcome to our office! We appreciate the confidence and trust that you have placed in us and look forward to meeting you personally and professionally. Our philosophy of care governs everything we do for