patient-details - westonfamilydentalflorida.com

Dental Patient Form

Patient Information

✓

Insurance Information

✓

Treatment Consent

✓

Payment Policies

✓

Dental History

✓

Medical History

✓

HIPAA

✓

0 of 7 Steps Completed

Patient Information

Please provide your personal details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Address *

City *

State *

ZIP Code *

Emergency Contact Name

Emergency Contact Phone

Insurance Information

Please provide account and insurance details

Person Responsible for Account

Is the person responsible for the account different than the patient?

Yes

First Name

Last Name

Relationship to Patient

Employment Information of Person Responsible for Account

Is the employment information of the person responsible for the account different than the employment information of the patient?

Yes

Employer Name

Job Title

Work Address

Work Phone

Years Employed

Primary Insurance

Does the patient have insurance?

Yes

Insurance Company Name

Policy Holder Name

Group Number

Subscriber ID

Date of Birth of Policy Holder

Relationship to Patient

Secondary Insurance

Does the patient have secondary insurance?

Yes

Insurance Company Name

Policy Holder Name

Group Number

Subscriber ID

Date of Birth of Policy Holder

Relationship to Patient

Authorization

All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize the dentist and staff to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to the dentist and staff. I permit a copy of this authorization to be used in place of the original. I give the dentist, staff, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.

Signature (Type your name to sign electronically) *

Date *

Consent for Treatment

Please read and provide your consent for dental treatment

Patient Name *

I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient.

Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care.

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

I have read, understood, and agree to the above treatment policy.

Signature (Type your name to sign electronically) *

Date *

Payment

Does the person responsible for the account already have an account with this office?

Yes

Notice: Payment is due at the time of service unless alternative arrangements have been made in advance.

Please choose a method of payment below. *

If Credit Card is your preferred method, please fill out the following information:

Type (VISA, MC, Discover, AmEx, etc.)

Credit Card Number

Expiration

Card Verification Code

Your credit card information is kept on file for outstanding account balances

Payment Policies

Thank you for taking the time to understand our payment policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our staff members for clarification.

For Patients with Dental Insurance

We accept dental insurance assignments with the understanding that any uninsured portion that is not covered by your insurance plan is to be paid by you at the time of service. As a courtesy, our office will file all applicable insurance forms.

Authorization

I hereby authorize payment directly to this practice of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of the dental treatment for the patient named below.

Signature (Type your name to sign electronically) *

Date *

Patient Name *

HIPAA Privacy Notice

Notice of Privacy Practices

Your Rights Regarding Your Health Information

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.

Patient Name *

Date of Birth *

Acknowledgment and Consent

I acknowledge that I have received a copy of this office's Notice of Privacy Practices *

I understand that I have the right to review the Notice prior to signing this consent *

I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations *

Communication Preferences

How would you prefer to be contacted for appointment reminders?

Phone Call

Text Message

Mail

May we leave voicemail messages regarding your dental care?

Yes

Patient/Guardian Signature (Type your name to sign electronically) *

Date *

Relationship to Patient