Patient Registration Form

Patient Information

Contact Information

Employment Information

Emergency Contact

Minor Patients (Under 18)

Responsible Party Information

Contact Information

Employment Information

Primary Insurance Information

Secondary Insurance Information

Patient Responsibilities: We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.

Insurance Plans: Your dental benefit is a contract between you or your employer and the insuring company. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the insuring company. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.

Our practice may NOT be a contracted provider with your insurance's network.

If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.

If we are not a contracted provider with your insurance plan, it is the patient’s responsibility to verify with the insurance company whether the plan allows patients to receive reimbursement for services from out-of-network providers. If your plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if that amount is different than our estimated patient portion of the bill. If you choose to not “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your insurance company and will be responsible for payment to our practice before or at the time of service.

Scheduling of Appointments: We schedule all our patients as promptly as possible and we try our best to stay on schedule to minimize your waiting. However, in rare circumstances, emergency patients may take priority and this may cause delays. Even so, we reserve the doctor's time on the schedule for each patient procedure so we require a 48 hour notice to reschedule an appointment. To serve all patients in a timely manner, we may need to reschedule an appointment if a patient is 15 minutes late or more. Late rescheduling, being late to an appointment, or missing an appointment may require rescheduling and may incur a fee of no more than $50 and/or a deposit to reserve future appointments. We appreciate your understanding and patience.

Authorizations: I understand that the information I have given today is correct to the best of my knowledge. I authorize this dental team to perform any necessary dental services that I may need and have consented to during diagnosis and treatment.