New Patient Personal Information
(Adult)
-Please Print-
Patient Information
Spouse Information

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.

Medical Information
Have you ever had any of the following? Please mark your response to indicate if you have had any of the following diseases or problems:
Joint Replacement
Cardiovascular
Women Only
Allergies - Are you allergic to or have had a reaction to (for all Yes responses, specify type or reaction):
Please list all current medications (or provide a list to front desk to copy into your chart)
Is there anything else we should know about your medical history?
DENTAL HISTORY
I have reviewed the above clinical examination and agree that it is accurate and complete to the best of my knowledge.
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:
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:
Third Occurrence:
Please sign and date below acknowledging that you have read and agree to these terms.
Thank you for understanding!
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.
Sapphire Dental Gorup, PC
2901 Brooks St., Ste. A-1
Missoula, MT 59801
www.montanasmiles.com
Phone: (406) 541-2886
Fax: (406) 541-2889