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Contact & New Patient Form

Choosing the right dentist for your dental needs is easy when you turn to us. We are honored to be your choice for excellent service that caters to your needs.For new patients please fill out the form below. We look forward to working with you!

Patient Registration ADC Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement with POC Medical Hx and Dental Hx Duplex

PATIENT REGISTRATION

PATIENT REGISTRATION

Please complete the following confidential information. To better serve you we require each area to

be filled completely, if something does not apply write N/A

A. DATE

FOR OFFICE ONLY

PATIENT LAST NAME

FIRST

M.I

PREFERS TO BE CALLED

BIRTHDATE

AGE

SOCIAL SECURITY #

SEX

MARITAL STATUS

ADDRESS

CITY

STATE

ZIP

HOME TELEPHONE

CELL

WORK

DAYTIME #

EMAIL ADDRESS

EMPLOYER NAME/ADDRESS

REFFERED BY

MAY WE THANK THEM BY LETTER

PREFERRED PHARMACY

PHONE #

PREFERRED PHARMACY

PHONE #

(If Applicable) NAME OF SCHOOL

YEAR

(If Applicable)SPOUSE’S/ PARTNER’S NAME

SPOUSE/ PARTNER’S WORK #

B. (If you have brought your Dental Card with you, you can omit section B!)

PRIMARY DENTAL INSURANCE

INSURED’S NAME

DOB

RELATIONSHIP TO INSURED

SSN

GROUP #

EMPLOYER NAME

INSURED’S ID#

INSURANCE COMPANY

SECONDARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

INSURED’S NAME

DOB

RELATIONSHIP TO INSURED

SSN

GROUP #

EMPLOYER NAME

INSURED’S ID#

INSURANCE COMPANY

C. (If Patient is responsible for account, write patient by NAME and the rest of section C can be omitted)

PERSON FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT

NAME

RELATIONSHIP TO PATIENT

SSN

ADDRESS

CITY

STATE

ZIP

PHONE

Free Text

EMERGENCY CONTACT

NAME

PHONE

ADDRESS

CITY

STATE

ZIP

CLOSEST RELATIVE NOT LIVING WITH YOU

CLOSEST RELATIVE NOT LIVING WITH YOU

NAME

PHONE#

ADDRESS

CITY

STATE

ZIP

FOR OFFICE USE ONLY

FOR OFFICE USE ONLY

Field label

New Field:

DISCLAIMER

DISCLAIMER:

Parents are required to remain in this dental office during their child’s dental visits. This affords parents the opportunity

to ask questions and our staff the opportunity to explain and discuss our findings. Also, circumstances may arise that

require a change in dental treatment, resulting in fee differences. If parental consent cannot be obtained, we

reserve the right to continue with treatment deemed necessary or to discontinue treatment and reschedule the

appointment. In certain instances, written permission from the custodial parent will be sufficient to allow another party

to bring this child to a scheduled dental appointment.

1. I agree to be present at

(CHILD'S NAME)

dental appointments.

Signature of parent/custodial parent

Date

Consent for Treatment

Consent for Treatment

I hereby authorize doctor or designated staff to perform a thorough examination, take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient)

1. I hereby authorize doctor or designated staff to perform a thorough examination, take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of

(Name of Patient)

Free Text

's dental needs.

Free Text

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. 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.

4. I agree to be responsible for payment of all services rendered on my behalf or my dependent’s, and it is understood that the dentist will not bill a third party for payment on my or my child’s behalf. I understand that payment is due at the time service is rendered unless written arrangements have been made with this office prior to treatment. In the event that payments are not received by agreed upon dates, I understand that a late charge may apply and will be added to my account. If required, I also understand that a check of my credit history may be made.

Patient’s Signature

Date

Witness

Parent/Responsible Party’s Signature

Relationship to patient