New Patient Adult Form

-Please Print-

Date

Home Phone

Cell Phone

Email Address

Patient Information

First Name Middle Name Last Name Preferred Name

Physical Address

City,State

Zip

Mailing Address

City,State

Zip

Employer

Work Phone

Sex:

M

F

Birthdate

Age

Social Security #

Dental Insurance Company

In case of emergency, who whould be notified?

Phone #

How did you hear about our office?

Who is responsible for payment on this account?

Self

Other

Relationship To Patient

If Other, Please Provide Full Name

Mailing Address

Phone #

Spouse Information

First Name Middle Name Last Name Preferred Name

Employer

Cell Phone

Sex:

M

F

Birthdate

Age

Social Security #

Dental Insurance Company

I authorize dental treatment for myself, and I accept full financial responsibility for all charges incurred in this office. Privacy Notification: I have been informed of office privacy policies and I authorize use of protected personal information about myself in accordance with these policies.

Signature

Date

By clicking here I agree that my name on this form constitutes a legal signature

Previous Dentist

City

Date of last dental visit

What is the primary purpose of your visit?

Become Established Patient for exams and cleanings

Improve my smile/Cosmetic concerns

Gum disease

Pain

Broken Tooth

Other

Do you have chronic headaches or neck and shoulder pains?

Yes

No

Have you ever had pain in your jaw joint or sides of your face or ears?

Yes

No

Have you come to this office for relief of pain?

Yes

No

Are you presently having dental pain?

Yes

No

Have you had the pain more than 3 weeks?

Yes

No

Are your jaws or teeth tired when you awaken?

Yes

No

Is any part of your mouth sensitive to temperature?

Yes

No

Is any part of your mouth sensitive to pressure?

Yes

No

Do you have any unpleasant odor or taste in your mouth?

Yes

No

Do you have any pain or soreness around the eyes or ears?

Yes

No

I have reviewed the above clinical examination and agree that it is accurate and complete to the best of my knowledge.

Signature

Date

By clicking here I agree that my name on this form constitutes a legal signature

NO SHOW/LATE CANCELLATION NOTICE

We hope that you understand the necessity of these charges for patients who fail appointment. This is to help protect you from increased fees to cover the cost of patients who do not keep their appointments.

Please initial next to each section after you have read and understand the following:

First Occurrence:

If a patient fails to give 24 hours notice to cancel an appointment, a $10.00 fee will be applied to their account.

If a patient fails to come to an appointment without calling in advance to let us know they can't keep the appointment, a $25.00 missed appointment fee will be applied to their account.

Please keep in mind that we completely understand cancelling due to hazardous weather and road conditions. The late fee will be waived in those circumstances.

Second Occurrence:

Same as the first

Third Occurrence:

A $50.00 deposit will be required prior to scheduling any future appointments. If the appointment is failed after a deposit is collected, the deposit will be forfeited and the patient will be dismissed from the practice. If the appointment is kept, the deposit is credited to their account.

Please sign and date below acknowledging that you have read and agree to these terms.

Thank you for understanding!

Signature

Date

By clicking here I agree that my name on this form constitutes a legal signature

Patient Payment Agreement For Family Dental Group

Please read the following; if you have any questions please ask. In the past we have found that most credit and collection problems are caused by a lack of communication.

Full payment for professional services is due at the time of treatment. All patients without dental insurance are required to pay in full at the time of service. We offer a 5% discount for accounts paid in full at time of service with cash, check or money order. Insurance, credit and debit card transactions are ineligible for this discount.

Family Dental Group is an independent dental clinic. This means we are not a network provider for any insurance company. Patients who have dental insurance are responsible for all charges. Full payment, for all services, is due at time of treatment. If your insurance allows assignment of benefits and pays us directly, only deductibles and our estimated copayments are due at each visit. Patients are reponsible for full payments on accounts over 60 days even if an insurance claim is outstanding.

PAY IN FULL Insurance: Some insurance companies do not allow assignment of benefits, meaning they do not pay providers directly. You will need to pay us in full for all services rendered on the day of service, and your insurance will reimburse you.

Payment Agreement:

I, , authorize treatment for myself or minor, and agree to pay all fees and charges for such treatment. I authorize rny dental insurance company or third party payer to make payments directly to Sapphire Dental Group, PC, d/b/a/ Family Dental Group and authorize the release of personal information or dental records (protected information) to other healthcare providers for the purpose of coordinating my healthcare. I also authorize release of protected information to my insurance company or third party payer for the purpose of reimbursement for services. I understand that I am responsible for payment of any unpaid balance due from my insurance company, within 60 days of treatment. I understand that overdue accounts will be sent to a collections agency and I authorize release of protected information for collections purposes. I also agree to pay an interest penalty up to15% on any outstanding balance over 60 days and a one time late fee not to exceed $20.00. I also agree to pay a $20.00 returned check fee for each returned check. I acknowledge receipt of a copy of this agreement.

Patient or Responsible Party Signature

Date

By clicking here I agree that my name on this form constitutes a legal signature

Sapphire Dental Gorup, PC
2901 Brooks St., Ste. A-1
Missoula, MT 59801

www.montanasmiles.com

Phone: (406) 541-2886
Fax: (406) 541-2889

Patient Validation: