1New Patient Registration Form
2Consent For Services
3Acknowledgement Of Receipt
4Missed Appointment Policy

New Patient Registration Form

    Back

    *Are required to register online

    *First

    *Last

    GenderMaleFemale

    Marital StatusSingleMarriedSeparatedWidowed

    *Date of Birth

    *Social Security Number

    Driver’s License Number

    *Are required to register online

    *Street Address

    Address Line 2

    *City

    *State / Province / Region

    *ZIP / Postal Code

    *Email

    Employer

    Occupation

    Are You a Full-Time Student?YesNo

    Home Phone Number

    Mobile Phone

    What is the primary reason for this appointment?

    Are you having any discomfort at this time?YesNo

    How did you hear about us?

    Web SearchReferred by Another Patient or FriendReferred by Another DoctorInsurance WebsiteInsurance DirectoryOther

    Spouse/Parent Information

    First

    Last

    Social Security Number

    Date of Birth

    Employer

    Occupation

    Address

    Street Address

    Address Line 2

    City

    State / Province / Region

    ZIP / Postal Code

    Phone

    Relationship to Patient

    Contact in Case of EmergencyYesNo

    Insurance

    We will file all necessary forms and reports to your insurance company. We do not render our services on the basis that the insurance company pay our fee. The patient/patient’s guardian is personally responsible for any fee the insurance company does not cover.

    Person Responsible for Account

    First

    Last

    Relationship to Patient

    Social Security Number

    Date of Birth

    Employer

    Primary Insurance

    Second Insurance

    Group Number

    Phone

    When was your last dental appointment?

    When was your last dental cleaning?

    When were your last dental x-rays?

    When was your last panoramic x-ray?

    Do you like your smile?

    Would you like to have whiter teeth?

    Do you want to keep your remaining teeth?YesNo

    Are any of your teeth loose?YesNo

    Have you had a bad dental experience?YesNo

    Do your gums ever bleed?YesNo

    Have you ever had periodontal treatment?YesNo

    Do you ever have cling, popping or discomfort in your jaw joint?YesNo

    Do you have difficulty in opening/closing your mouth?YesNo

    Does food catch in between your teeth?YesNo

    How often do you brush your teeth?

    Type of toothbrush?

    Do you floss?YesNo

    Do you take fluoride supplements?YesNo

    Have you noticed any lumps, growths or swellings in your mouth?YesNo

    Are your teeth sensitive to cold? Heat? Sweets? Pressure?YesNo

    Have you ever had orthodontic treatment (braces)?YesNo

    Do you / have you ever smoked or chewed tobacco?YesNo

    How much do you smoke now?

    When did you quit smoking?

    Have you used recreational drugs?YesNo

    If there was anything you could change about your smile what would it be?

    Who was your last dentist?

    First

    Last

    Why did you leave your last dentist?

    Are you taking Aspirin, other over-the-counter drugs, or Vitamins?YesNo

    Are you allergic to any medications?YesNo

    Medical History

    Are you under care of a physician?YesNo

    Have you been hospitalized or had an operation?YesNo

    Have you ever had a head or neck trauma?YesNo

    Are you taking any medications?YesNo

    Serious Illness History

    Heart TroubleHeart MurmurRheumatic FeverArtificial Heart ValveHeart Pace MakerHeart SurgeryMitral Valve ProlapseIrregular Heart BeatAngina / Chest PainHeart Attack / FailureHigh Blood PressureLow Blood PressureBleeding DisorderConvulsionsAlzheimer's DiseaseHives / RushTuberculosisSickle Cell DiseaseLeukemiaBlood TransfusionLung DiseaseBruise EasilyAnemiaAsthmaSinus TroubleFrequent CoughShortness of BreathEmphysemaRadiation TreatmentChemotherapyArthritis / GoutUlcersRecent Weight LossFrequent DiarrheaDiabetesFrequent ThirstHypoglycemiaLiver DiseaseStrokeTumors / GrowthsPsychiatric CareCongenital Heart DisorderYellow JaundiceKidney ProblemsRenal DiseaseThyroid DiseaseParathyroid DiseaseVenerial DiseaseCold Sores / Fever BlistersGenital HerpesDrug AddictionCortisone MedicineRheumatismStomach / Intestinal Problems

    Women

    Pregnant/Trying to get pregnantNursingTaking oral contraceptives

    As a condition of treatment by this office, financial arrangements must be made in advance.
    We will prepare and file you Insurance Claim for you, however, you must understand that:

    Dispute Resolution

    Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to this contract. Our relationship is with you. We cannot become involved in disputes between you and your insurer regarding deductibles, co-payment, covered charges and “usual and customary” charges.

    Our Role

    We are contracted with certain PPO Insurance Plans, we will follow the guidelines for patient care, reimbursement and submission for claims for services rendered. Any contractual discounts will be deducted from your balance.

    Your Responsibility

    All charges are your responsibility whether your Insurance Company pays or does not pay. Not all services are a covered benefit in all contracts. Some Insurance Companies arbitrarily select certain services they will not cover.

    Payments

    Fees for these services, along with unpaid deductibles are due at the time of treatment. We collect the portion not expected to be paid by the Insurance Company, send all claims and wait up to a maximum of 60 days for the Insurance Company to pay on a claim from the day of treatment.

    There is a service charge of 1.5% per month (18% per annual) on the unpaid balance on all accounts exceeding 60 days. In addition, should this account be forwarded to a Collection Agency, you agree to be responsible for any and all Collection Cost charged to this office related to the agency collection efforts. There is a $35.00 charge for returned checks or charge card returns.

    I understand a fee estimate listed for dental care can only be extended for a period of 6 months from the date of examination. On PPO’s the fees is set by your Insurance Company and subject to change without notice by your Insurance Company.

    WE RESERVE THE RIGHT TO CHARGE A PER HOUR FEE FOR BROKEN OR MISSED APPOINTMENTS UNLESS 48 HOUR ADVANCED NOTICE IS GIVEN.

    In consideration for professional services rendered to me, or at my request, by the Doctor, I agree to pay the reasonable value of said services to Doctor, or his associate at the time services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me in writing, within the time for payment thereof.

    Name

    First

    Last

    *Date

    I authorize release of information to the Insurance Company necessary the processing of dental insurance claims and further authorize payment of dental benefits directed to FAMILY DENTISTRY OF SAN ANTONIO.*

    Please Sign Here*

    * You May Refuse to Sign This Acknowledgement *

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
    DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    This Notice of Privacy describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

    "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future dental condition and related health care services.

    We reserve the right to change our privacy practices and the terms of this notice at any time, provided such applicable law permits the changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

    You may request a copy of our notice at any time.

    USES AND DISCLOSURES OF HEALTH INFORMATION

    We may use and disclose your health information for different purposes, including treatment, payment and healthcare operations.

    Treatment: We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

    Payment: We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved in your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

    Healthcare Operations: We may use and disclose your health information in connection to our healthcare operations. This includes, but is not limited to, quality assessment activities and employee review activities. We may also call you by name in our waiting room when your dentist or hygienist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

    To You and Your Family: We may disclose your health information to a family member who is responsible to the extent necessary to help with your healthcare or with payment of your healthcare. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity, or an emergency, we will disclose your dental information based on our professional judgement or whether the disclosure would be in your best interest.

    Required by Law: We may use or disclose your health information when we are required to do so by law.

    Revoke This Authorization: At any time, in writing, you may revoke this authorization, except to the extent that your dentist or dental practice has taken an action in reliance on the use or disclosure indicated in the authorization.

    YOUR RIGHTS

    You have the right to Inspect and copy your protected health Information with limited exceptions. You must make the request in writing. If you request information that we maintain on paper, we may provide photocopies. If you request information we maintain electronically, you have the right to an electronic copy.

    If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

    You have the right to request a restriction: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your dentist is not required to agree to a restriction that you may request. If the dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

    If you have any questions or concerns, please contact us.

    I have received a copy of this office’s Notice of Privacy Practice.

    Please Print Name

    *Date

    Please Sign Here*

    For Office Use Only

    We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

    Individual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther

    Many offices charge their patients when they don’t show up of for appointments or fail to let the office know with 48 hours advance notice that they can’t make the scheduled appointment. In many cases offices charge a fee every time a patient fails to make their scheduled appointment times.

    We reserve a specific time for your appointment and strive to be on time to minimize your waiting time. As a General rule we are pretty good at seeing patients within 15 minutes of their scheduled appointment time. It is a common courtesy to let us know if you cannot make your appointment as scheduled and to fail to do so is rude and disrespectful. When a patient fails to make their scheduled appointment it leaves the office with empty chairs and employees with nothing to work on (but still being paid their salary). It increases the cost of doing business and can lead to higher costs for all patients.

    Once an appointment is made by you, the patient, we consider the appointment as a confirmed appointment unless the patient contacts us to cancel or charge the appointment. We do attempt to refresh your memory regarding the appointment by email, and phone calls prior to the actual date of the appointment, but if we don’t reach you personally you still have a confirmed appointment with us.

    WE CONSIDER A MISSED APPOINTMENT AS ANY APPOINTMENT YOU FAIL TO SHOW UP FOR OR ANY APPOINTMENT YOU CANCEL OR CHARGE WITH LESS THAN 48 HOURS ADVANCE NOTICE.

    We do understand that stuff happens. There may be times when last minute situations come up and you just can’t make your appointment. We allow 2 missed appointments within 18 consecutive months.

    On the THIRD missed appointment we charge $50.00 per hour for the time you missed.

    Name

    First

    Last

    *Date

    Please Sign Here*