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Anthony Dental Care | New Patient Forms
16621
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New Patient Forms

We are asking you to complete new patient questionnaire enabling our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier. Our questionnaire consists of 3 documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields, marked by asterisks, must be completed. When you have completed a document please review your entry, click the Next button to move to the next document. Please don’t use your browser’s Back or Forward buttons. Use of these buttons may ‘undo’/’redo’ your recent actions and may result in errors. Please note that the information you will submit will be encrypted for your protection and goes directly to our office. We appreciate the time that you will spend providing the information helping us prepare for your visit.

New Patient Forms

Anthony Dental Care: New Patient Registration

NEW PATIENT FORMS

Responsible Party

(if someone other than the patient)

Emergency Contact

Primary Dental Insurance Information

INSURANCE CARD NEEDS PRESENTED TO FRONT DESK

Secondary Dental Insurance Information

INSURANCE CARD NEEDS PRESENTED TO FRONT DESK

Consent for use and disclosure

Please read the following statement carefully.

Purpose of Consent: By signing this form, you will consent to use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Right to Revoke: You will have the right to revoke the Consent at any time by giving us written notice of your revocation submitted to the Consent Person listed on your Privacy Notice. Please understand that revocation of this Consent will not affect any action we took in reliance to this Consent before we received your revocation, and that we may decline to treat your or to continue treating you if you revoke this Consent.

To Whom may we speak to about personal dental records and/or personal financial record concerns for this patient. (ex: spouse, grandparent, friend, care giver, etc……)

Authorization

By checking this box, I understand that above Notice of Policy Practices and may request a copy of the Notice of Privacy Practices from Anthony Dental Care, LLC at any time.
I understand that an electronic signature has the same legal effect and can is the same as a written signature.

AUTHORIZATION AND CONSENT FOR SERVICES / FINANCIAL RESPONSIBILITY

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
I authorize the diagnosis of my dental health by means of radiographs or other aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payers, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.


The practice depends upon reimbursement from patients for the cost incurred in their care. Financial responsibility on the part of each patient should be determined before treatment.

Patient with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be honored for a period of six months from the date of the patient information.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.
By checking this box, I acknowledge that I have read the above conditions and agree to the contents.
I understand that an electronic signature has the same legal effect and can is the same as a written signature.