Fulks Family Dentistry New Patient Form

Appointment Policy Acknowledgement
Thank you for choosing our office to serve you with your dental needs. We strive to see our patients in a timely manner for each and every appointment. In addition, we want to be able to be available to our patients when they have a dental emergency.

In order to achieve these goals, it is imperative that we receive at least a 24 hour notice for appointment changes. If multiple appointment changes are made, less than 24 hours prior to the scheduled appointment, we may no longer be able to reserve a time for you on our schedule without a reservation fee.
Please initial here that you agree with our Appointment Policy Acknowledgement*
Please list below the best ways to reach you regarding your reserved appointments. Fill out all that apply
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Work Phone Extension
Other Phone

Area CodePhone Number
Specify "Other Phone"
Late Arrival Policy

Late arrivals are handed on a case by case basis. It is vital that you are in our office, ready for your appointment, at your reserved appointment time. Late arrivals may result in your appointment being rescheduled so we may see the rest of the day's scheduled patients on time.
Name of signee whether patient or parent of patient:

First NameLast Name
By signing, I acknowledge that i have read and understand the above policy.

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Date

MonthDayYear
Date

Fulks Family Dentistry

3316 HWY 5 N. Suite 1

Bryant, AR 72019

(501)847-6453

Written Financial Policy

Thank you for choosing Fulks Family Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients, by offering several payment options.

Payment Options:
- Cash, Check, Visa, Master Card, Discover Card, or American Express
- Convenient monthly payment plans from Care Credit
  1. Allows you to pay over time
  2. No annual fees or pre payment penalties
  3. 12 months, no interst for charges over $1000.00
Please Note:

Fulks Family Dentistry requires payment prior to the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less then the cost of care received.

For patients with dental insurance, we are happy to work with your insurance carrier to maximize your benefit and directly bill them for reimbursement for your treatment. Most insurance plans are accepted at our office however, please note that INSRUANCE IS INTENDED TO COVER SOME COST, BUT NOT ALL COST OF TREATMENT. We can only give patients an insurance estimate. You are responsible for all expenses not covered by your medical insurance. Patient portions are due at the time of service. After your insurance has paid, if there is a remaining balance, you will receive a statement of your account balance.

Fulks Family Dentistry charges $25.00 for returned checks

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want and/or need.
Name of signer whether patient or parent of patient

First NameLast Name
By signing, I acknowledge that i have read and understand the above policy

Clear
Date

MonthDayYear
Date

HIPAA

Fulks Family Dentistry

Clint Fulks, D.D.S

3316 HWY 5 North. Suite 1

Bryant, AR. 72019

(501)847-6453

Consent for Use and Disclosure of Health Information

Section A: Patient Giving Consent
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section B: To the Patient – Please Read Carefully

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

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting the office manager.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

Clear
Date

MonthDayYear
Date
Section C: Additional People to have access to information

I would like to give the following persons access to personal health information. (ex: spouse or family)
Name

First NameLast Name
Relation
Name

First NameLast Name
Relation
Name

First NameLast Name
Relation
If you are signing as a personal respresentative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Relationship to patient
Name

First NameLast Name
Source of Authority
Should be Empty:

Patient Registration

Please fill out the Responsible Parties Information Below

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Medical History

Appointment Policy Acknowledgement