New Patient Form

New Patient Form

We would like to get to know you better!

Basic Information
Name*

First NameLast Name
If Child Parents Name
Date of Birth*

MonthDayYear
Date
Age of Patient*
Gender*

MaleFemaleOther
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Would you like to receive text alerts?*

YesNo
Occupation*
Employer*
Employers Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employers Phone Number*

Area CodePhone Number
Spouse Name if Applicable

First NameLast Name
Spouse Occupation
Spouse Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Employer Phone Number

Area CodePhone Number
Who referred you to our office?
Person responsible for dental investment?*

Insurance Information
Name of Insurance Carrier (if no insurance indicate none)*
Social Security Number (no dashes or spaces)*
Group Number
Are you covered by another plan? If so other plan Carrier.
Social Security Number
Group Number

Privacy Practices Information
Brandon Hodge, D.D.S.

General and Family Dentistry

Health care professionals are now required by law to inform you of our efforts to protect you privacy concerning information you provide to us for diagnosis, treatment, and follow-up care. This is a summary of those efforts we have made in the past and will continue in order to protect you.

A complete copy of the Notice of Privacy Practices is available to you in the front office.

• In office records are not accessible to persons other than our staff.
• Only pertinent information is provided to referral sources and only when we have recommended a referral to another health care provider in agreement with you.
• Only pertinent information is provided to your insurance carrier when assisting in filing a claim on your behalf.
• Protection is placed on any information transmitted from our office electronically or by mail.
• No patient information is emitted from our office for any reason other than patient care.

I have received notice of this office's Privacy Practice Policies.
Signature*

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Office Policies & Payments
Brandon Hodge, DDS 1020 Antebellum Circle

Hendersonville, TN 37075

615-822-5678

Office Policies (Please read and sign below)

We are honored that you have chosen our staff to provide your dental care. Your dental health is our greatest priority. For your convenience, we would like to inform you of our office policies in advance. You may have dental insurance, which is a contract between you, your employer, and the insurance company. We must emphasize that as medical care providers, our relationship is with you, and not your insurance company. Some insurance companies arbitrarily select certain services they will not cover, and most procedures are only covered at 50% or 80%. While the filing of insurance claims is a courtesy that we extend to our patients, and we will attempt to help you understand how your policy applies, you are ultimately responsible for all fees incurred beginning on the date services are provided.

Payment

Payment in full is due at the time of service. This includes all co-pays, deductibles, and co-pay percentages. We accept cash, Mastercard, Visa, and Discover. If you need to set up a payment plan, this service is provided through Care Credit. Please ask our front office personnel for information on Care Credit.

Unpaid Balances

There will be a fee of $25.00 for each returned check. In the event that your account is placed with an outside collection agency, you will be responsible for all costs incurred to collect on the account.

Cancelled Appointments

When you reserve time in our schedule for an appointment and fail to show, or cancel less than 24 hours before your scheduled appointment, you have prevented another patient the opportunity to use that time. Should you have a need to cancel or reschedule your appointment we ask that you advise us a minimum of 24 hours in advance of your scheduled time. Failure to notify the office will result in a $40.00 charge to your account. If you arrive late for your appointment we may need to reschedule on another day.

I hereby agree to these policies and accept responsibility for charges not covered by my insurance carrier. I also agree to reimburse Dr. Brandon Hodge for fees incurred to collect on my account, including collection fees, attorney fees, court costs, and all other costs related to the collection of my account.

I have read, understand, and agrees to these policies.
Signature

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