New Patient Registration

In order to effectively serve you, please fill out the information below as completely and accurately as possible. You will be prompted to e-sign at the end of the form. All information is strictly confidential.

First Name *

Middle Initial

Last Name *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

DOB *

Month Day Year

Sex *

M F T

Email Address *

I authorize Blueridge Dental to email me (including appointment reminders, product information and promotions)

Yes No

Phone1 *

Type *

Other

Phone2

Type

Other

Phone3

Type

Other

Preferred Method of Contact (Select all that apply):

E-mail Cell (Text) Cell (Phone) Home Work Other

Who may we thank for referring you?

Are you personally responsible for your financial account? *

Yes No

Is the person who is financially responsible for your account present now so that they can sign the Blueridge Dental Financial Agreement form? *

Yes No

You have indicated that you are not personally responsible for your financial account. It is important that the person who is responsible provides us with a signed copy of the Blueridge Dental Financial Agreement prior to your first/next visit.

Please have them fill in their information and read and sign the Financial Agreement below before proceeding.

You have indicated that you are not personally responsible for your financial account. It is important that the person who is responsible provides us with a signed copy of the Blueridge Dental Financial Agreement prior to your first/next visit.

Please fill in the responsible person’s information below and we will contact them regarding the Blueridge Dental Financial Agreement.

Financially Responsible Person’s Information:

Name *

Enter full name

Contact no. *

Email *

example@example.com

Relationship to the patient *

Address *

DOB *

Month Day Year

Your dental insurance is an agreement between you, your employer and the insuring company. We are happy to bill your insurance company directly whenever possible. Please be aware that:

1. You are fully responsible for all fees associated with your dental treatment.

2. You are responsible to know your insurance: what’s covered, deductible amounts, limits, etc.

3. Notify us of any changes to your dental insurance.

4. You consent and authorize Blueridge Dental to submit claims electronically to your insurance company, to contact your insurance company for any information required related to claims, payment, coverage, eligibility, etc.

5. You must pay your estimated portion of the fees, when required at each appointment.

6. All major procedures (e.g. crown, bridge, implants, etc.) will be non assignment. We will submit these claims to your insurance on your behalf. Any reimbursement will be sent to the subscriber. Full payment is required at time of service.

7. Any fees not covered by your insurance will be your responsibility. (Most insurance carriers do not pay 100% of the treatment costs for a variety of reasons.)

8. We will allow 3 months from your appointment to receive payment from your insurance company. If payment is not received after this time, you will be responsible to pay the full amount.

Our office will submit insurance claims on your behalf to your insurance company for any contribution they may provide for your treatment. Please note that once your insurance carrier has paid their portion, or after 3 months post-treatment has elapsed, any remaining balance is your responsibility.

In an effort to limit person to person contact in our front office environment, and to keep accounts current, we are asking patients to leave a credit card on file. The credit card will be used to cover your patient portion due at time of service. Once payment is received from your insurance, any remaining balance on your account will be promptly charged to your credit card. We will notify you by email or text two business days before applying this charge.

* For security purposes, we do not collect any credit card information on this form. We will request this information when scheduling your appointment or at first visit.

I, the undersigned, certify that I have read, understood and agree to Blueridge Dental's Financial Agreement.

Name of Undersigned *

Who is signing? *

e-Signature *

Clear

Do you have dental insurance? *

Yes No

Primary Policy Holder's Information:

Name *

DOB *

Month Day Year

Employer *

Insurance Company *

Group/Policy # *

ID or Certificate # *

Secondary Policy Holder's Information:

Name

DOB

Month Day Year

Employer

Insurance Company

Group/Policy #

ID or Certificate #

It is your responsibility to be present for your appointment. We consider appointments confirmed at the time of booking. Should you need to change your appointment we require 2 full business days notice. Unless previously arranged, we do not permit appointment changes via email. We reserve the right to charge your account for missed or short notice cancelled appointments.

Patient's Initials *

PERSONAL INFORMATION

FINANCIAL AGREEMENT

INSURANCE INFORMATION

APPOINTMENTS

DENTAL HISTORY

MEDICAL HISTORY

PRIVACY, DISCLOSURE & CONSENT

ACKNOWLEDGEMENT REGARDING INFORMATION PROVIDED