New Patient Paperwork

Patient Information

Thank you for trusting us with your dental care! We promise to provide you with the finest care available. Please fill out this form completely. The better we communicate, the better we can care for you.
Patient Name *

First Name Middle Name Last Name
Gender: *
Date of Birth: *
MM/DD/YYYY
Phone Number *

Area Code Phone Number
SSN:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address:
example@example.com
Best Way to Confirm Appointments (please check to all that applies):

Text Message Call Reminder

Parent/ Legal Guardian Information

(Only if patient is under 18 years of age)
Parent/Legal Guardian name:

First Name Last Name
Date of Birth:
MM/DD/YYYY
Phone Number:

Area Code Phone Number
Relation to patient:
Insurance Information

If you are insured by a plan, please provide the following information:
Type of Insurance:
Insurance Company:
Primary Insured's name:

First Name Last Name
Primary Insured's Date of Birth:
MM/DD/YYYY
Primary Insured's SSN or Member ID:
Some Insurances only use SSN as identifier Ex: Metlife
Insurance Contact Number:

Area Code Phone Number
Emergency Contact Information

In case of an emergency, please list the best person to contact:
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Relation to Patient: *
Referral Source

We love new patients & would like to know how you heard about us! Please check all that apply:
Referrals:

Google Website Marketing Team Event: Friend/Family Member: Facebook Instagram Flyers

Notice of Privacy Practices
Acknowledgement of Notice of Privacy Practices

I hereby acknowledge that I have reviewed this practice's Notice of Privacy Practices. I further Understand that the practice will offer me updates to this notice. Should it be modified or change in any way I will received an updated copy.
This notice describes how medical health information about you may be used and disclosed and how you can get access to this information. Please read it and review it carefully.

By law we are required to provide you with our Notice of Privacy Practices (NNP). This notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

As a patient, you have the following rights:
- The right to inspect a copy of your information
- The right to request corrections to your information;
- The right request your restricted information;
- The right to request confidential communications
- The right to a report of disclousre of your information; and
- The right to a paper copy of this notice.
We want to assure you that your medical protected health information is secure with our practice. This notice of Privacy Practices contains information about how we ensure that your information remains private.

The following person(s) are authorized to have access to billing, appointment, and treatment information.
Name:

First Name Last Name
Relation:
Name:

First Name Last Name
Relation:
Name of Patient: *

First Name Last Name
Signature of Patient or Parent/Legal Guardian (if patient is under 18) *

Clear

Missed Treatment Appointment Policy
At Del Rey Dental, we put our faith in you to keep your appointment. When we set up an appointment, a specific amount of time is reserved especially for you. Many offices double or even triple book appointments to prevent from being financially damaged as a result of a missed appointment. However, double booking appointments does not allow us to give the care and attention needed to provide excellent quality dentistry and for this reason we choose to not do it.

Also, please DO NOT bring infants or children to your appointment as this will delay your visit with the dentist. In the case, you do bring children to your appointment please bring a person over the age of 18 yrs. old to supervise children in the waiting area.

Treatment appointment will require 30% down to schedule appointment and reserve your spot with our dentist. It is a

non-refundable fee but will be applied to scheduled treatment.

If for any reason you must cancel or change your appointment, it is important that you give our office at least 24- hours’ notice to offer that spot to someone else. You will be notified in these 3-ways to confirm your appointment if you are not sure or need to cancel please notify us when we call or text.

You will be texted ONE WEEK before your appointment to confirm.
You will be called 3 DAYS before your appointment day to confirm.
You will be called 1 DAY before your appointment day to confirm.
At the bottom provide the phone number you can be reached at.
If you DO NOT respond to any of these attempts, we reserve the right to cancel your appointment in order to give another patient the available time.

Late arrival: When we reserve time for you, we require all of the time to provide you with the best quality work possible. When you are late it decreases our ability to accomplish this. If you arrive more than 15 minutes late, your appointment may be rescheduled in order to meet the needs of those who are on time for their pre-reserved visit. If this happens it will be considered a missed appointment.

I have read the policy above. I understand and agree to abide by the listed terms. The decision to place patients account back in good standing lies at the sole discretion of the office manager.
Name of Patient: *

First Name Last Name
Signature *

Clear

Patient Responsibility
I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any dental service or visit, routine examination, x-rays, and any other service ordered by the doctor or staff.

I understand that while my insurance may confirm my benefits, confirmation of benefits is NOT a guarantee of payment and that I am responsible for any unpaid balance.

I understand and agree that it is my responsibility to know if my insurance has any deductible, copayment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.

I understand that without this consent, my insurance will NOT pay for any services and that I will be financially responsible for all services rendered.

I agree to inform the office of any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full. If the office does not have the proper information for a secondary insurance, the secondary will not be billed. It will be my responsibility to pay the balance and then file a claim with the secondary for reimbursement.

By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment and dental care operations, and/or as required by law.
Name of Patient: *

First Name Last Name
Signature *

Clear
Should be Empty:

Patient Information

Parent/ Legal Guardian Information

Insurance Information

Emergency Contact Information

Referral Source

Medical History

Notice of Privacy Practices

Missed Treatment Appointment Policy

Patient Responsibility