Combined Consent Form
When you come to the office the first time, you will be asked to sign a form indicating you:
- Have received a copy of the office privacy (HIPAA) policies;
- Agree to the office financial policy; and
- Give your consent for diagnosis and treatment.
Patient Information/Medical History Form
Upon your first visit to our office, you will also be asked to complete a medical history form & patient information on a tablet (iPad).
Please remember to bring a complete list of medications (If any) with you to your first appointment.
Patients need to provide their dental insurance number, insurance provider’s name and address (not medical insurance). It is the patient’s responsibility to be aware that your dental insurance covers the treatment provided or rendered.
- The fee for your treatment will be presented at your first visit and is due in full upon completion unless specific insurances are involved. For your information and planning, a statement will be provided upon your first visit.
- Regarding billing for self pay and uninsured, when you come in to our office, you will be immediately informed of our financial policy electronically through our web based practice management software: Dental EMR.
- We will provide information for pre-authorization upon request.
- We will be happy to complete any insurance forms. However, you are responsible for payment unless otherwise directed by the insurance company.
- Special financial arrangements must be approved by the Office Manager.
- When appointments are broken, full remittance is expected before completion of treatment.
We respect your right to privacy as it relates to your treatment and personal information. We also acknowledge our legal obligation to keep private any health information that identifies you. As part of that obligation, we are required to provide you with formal notice of our privacy practices. Click on the button below to review how we protect your health information and your rights regarding the use of your personal information. The document will open in a new window.
If you can’t fill out the forms, please arrive 15 mins prior to the appointment given.