New Patient Form - Dr. Todd J. Ayars, DDS PA

Dr. Todd J. Ayars, DDS PA

536 E. Pleasant Run Rd. Desoto, TX. 75115 | 972-296-9976
Child's Full Name*
Gender*

MaleFemaleNon-Binary
Date of Birth*

MonthDayYear
Child Lives With:*
Father/Stepfather's Full Name*
Home Address*
City*
State*
Zip*
Cell Phone*
Home Phone*
Work Phone*
Mother/Stepmother's Full Name*
Home Address*
City*
State*
Zip*
Cell Phone*
Home Phone*
Work Phone*
Best Contact Email*
Referral Source*

GoogleFacebookWord of MouthDental OfficeInsurance
Dental Insurance Information
Insured's Name*
Date of Birth*

MonthDayYear
Relationship to patient*
Insurance Company*
Insurance Phone*
ID/SS#*
Employer*
Group ID*
Authorization for Treatment
I authorize this dental office to perform examination, including necessary radiographs (x-rays), and after explanation, the necessary dental services deemed appropriate for the care of the above- named child. In addition, I agree to pay for all charges incurred resulting from said dental treatments, including Insurance deductibles and co-payments.

Person to Contact In Case of Emergency who DOES NOT live at the same address:
Full Name*
Phone*
Relationship to Child*
Guardian Signature:*

Clear
Date:*

MonthDayYear
Medical History
Child's Physician*
Phone*
Address*
Date of last physical exam*

MonthDayYear
Is your child in good general health?*
Describe your child’s social development*

NormalAdvancedDelayed
Please list some words which describe your child's personality/temperament*
Is your child taking any medications?*

YesNo
If yes, please list names and dosages*
Has your child had any reactions or allergies to any medicines?*

YesNo
If yes, please list*
Has your child ever had any of the following medical problems?*

AsthmaBirth DefectsEye DisordersLiver ProblemsFood AllergiesDifficulty w/SpeechKidney ProblemsHepatitisJaundiceDifficulty w/HearingSeizure DisorderHemophiliaBlood TransfusionDiabetesHeart DiseaseHeart MurmurRheumatic FeverEndocrine DisordersTuberculosisLeukemiaTumorsHIV/AIDSRecurrent InfectionsHospital StaysMedical OperationsTrauma/InjuryRecurrent HeadachesTMJ/TMDBehavior DisordersLearning DisordersMental RetardationHandicaps/DisabilitiesOther
Relationship to Child*
Signature:*

Clear
Date:*

MonthDayYear
Financial Agreement
Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality lifetime dental care so that you may fully attain optimum oral health. Everyone benefits when office and financial policy arrangements are understood. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Agreement which we require you to read and sign prior to any treatment.

Regarding Payment

Payment of estimated patient portion is due at the time of treatment. We desire to make dental treatment affordable to all of our patients. Therefore, we offer the following payment options:

1) We accept the following forms of payment: Cash, Visa, and MasterCard.

2) Flexible payment plans of up to 6 months upon approval with Care Credit®. Approval must be received prior to the treatment date.

Payment for services is due at the time services are rendered unless prior arrangements have been made with the doctor and the billing receptionist.

The parent that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with the doctor and billing receptionist.

Regarding Insurance

      As a courtesy to you, we will gladly process your insurance claim forms. Our responsibility is to provide you with the treatment that best meets your needs, not to try to match your care to insurance plan limitations. Dental insurance plans do not correspond to individual patient needs, and as such, many routine and necessary dental services are not covered even though you may need those services. We understand insurance guidelines can be difficult to understand and overwhelming at times. Fortunately, with the information provided to us by you and your insurance company, we are able to provide some assistance in estimating your insurance benefit. However, your insurance company makes final determination once treatment is completed and the claim is submitted.

Your insurance is a contract between you and your insurance company; therefore, all charges are your responsibility. All insurance co-pays and deductibles must be paid at the time of service. In the event we do accept assignment of benefits and your insurance company has not paid your account in full within 60 days, the balance may be transferred to your account. Your complete insurance information must be presented at the time services are provided. Insurance claims cannot be backdated. Most benefits will be verified before your insurance company can be billed.

Financial Agreement

     All insurance benefits are payable to the dental office, and I agree to release any information necessary for the dental office to process claims. We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

I realize I am financially responsible for all charges incurred, regardless of insurance coverage. I am responsible for all collection costs incurred by the dental office once the account is turned over to a collection agency.

Regarding Appointments

     Your reserved time in our office is important. We understand that sometimes it is necessary to change your appointment, so we ask that you kindly give us a minimum of 2 business days notice. Without this notice, we are unable to offer treatment to other patients that may have needed our care. If 2 or more appointments are broken in a 12 month period without 2 business days notice, a cancellation fee of $50 will be applied to your account.

Thank you for understanding our Financial Agreement. Please let us know if you have any questions or concerns.

I have read Dr. Ayars’ Financial Agreement. I understand and agree to this Financial Agreement.
Signature*

Clear
Date*

MonthDayYear
HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that:

-Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

-The practice reserves the right to change the privacy policy as allowed by law.

-The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

-The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

The practice may condition receipt of treatment upon execution of this consent
May we phone, email, or send a text to you to confirm appointments?*

YesNo
May we leave a message on your answering machine at home or on your cell phone?*

YesNo
May we discuss your medical condition with any member of your family?*

YesNo
If YES, please name the members allowed:
This consent was signed by:*
Print Name
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Dr. Todd J. Ayars, DDS PA

Dental Insurance Information

Authorization for Treatment

Medical History

Financial Agreement

HIPAA Compliance Patient Consent Form