Patient Intake Form

NEW PATIENT REGISTRATION --

Address

Telephone

INSURANCE INFORMATION --

* Please present your insurance card to be photocopied for our records.

RESPONSIBLE PARTY (if patient is a minor or different from patient listed above) --

Address

Telephone

EMERGENCY CONTACT --

AUTHORIZATION --

I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child’s) health care, advice, and treatment to another dentist, or for evaluation and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to the practice and understand my insurance may pay less than the actual bill for services and that I am responsible for any services not paid or covered.

ELECTRONIC COMMUNICATIONS --

I consent to receiving HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment, etc. I understand there is no obligation to receive these electronic communications.

MEDICAL HISTORY --

Patient

Are you currently under the care of a physician?

Have you ever taken Bisphosphonates (IV or Oral)? If yes, please list type and dates taken

Are you taking any blood thinners? If yes, which one(s)

List all medications you are taking:

Women Only

Please check if you have/had:

DENTAL HISTORY:

APPOINTMENT CANCELLATION POLICY

In our dental practice, we respect the importance of your time and we work very hard to schedule appointments that accommodate the scheduling needs of all our patients. We want you to know that we make every effort to see you at your scheduled appointment time. We greatly appreciate that you notify us at least 48 business hours prior to your scheduled appointment time, if you must CANCEL or RESCHEDULE your appointment. Please also note that a cancellation fee may be charged for an appointment if the appointment is cancelled or rescheduled without at least 48 hours notice.

FINANCIAL POLICY

All payments/co-payments for services are due at the time dental treatment is provided. Every effort will be made to provide a treatment plan for services with estimated costs so that you can be prepared for payment on your next visit. As a courtesy to our patients, if you have dental insurance, we will file your dental insurance claims and bill your dental insurance company for the treatment you receive. However, in the event the insurance company does not pay the estimated portion of the bill, the balance will become the patient’s responsibility and will be billed directly to you.

PHOTOGRAPHY RELEASE/CONSENT

I, hereby give Dr. Tania Saint at Parkland Orthodontics and any of the employees the right and permission to use and/or publish photographs of me for clinical purpose only.
Release of Claims: I, hereby release and discharge Dr. Tania Saint at Parkland Orthodontics and everyone functioning under her permissions or authority from any legal or equitable claims.

Check on the following:

Yes, you may use my photos.No, please do not use my photos.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES / USE AND DISCLOSURE FORM

Please leave this field empty.