www.transcendentist.com - New Patient Form

New Patient Form
GETTING TO KNOW YOU

Welcome to Transcendentist and the office of Dr. Sangha and Dr. Praj Kamat! We are committed to your total wellbeing and to helping you take the best of your mouth. We know this is an extensive questionnaire, and thank you for taking the time to answer as completely as possible.
What is your name?*

First NameLast Name
How would you like to be addressed?*
Please give us your full mailing address.*

Street Address

Street Address Line 2

CityState

Zip Code
Do you have an email address?*
We do not share email addresses with anyone
What is your birth date?*

MonthDayYear
Date
Gender*
Please Specify*
What sex were you assigned at birth?*
What is your social security number?
Please provide us with the following telephone numbers
Please check the best number to reach you.

Home Phone NumberWork Phone NumberCell Phone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Please provide an emergency contact person and contact information.

(if the information is different from yours).
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Relationship
Financial Practices & Consent for Treatment
FINANCIAL PRACTICES
We are committed to partnering with you in the health and well-being of your mouth. As such, we feel it important that our financial arrangements and treatment decisions are direct with you and are not dictated by a third party. Ours is a “Fee for service” practice, which means that we request payment at the time services are rendered. In addition to cash and checks, we accept Visa, MasterCard, Discover, and American Express, and in certain pre-arranged cases, you can pay your obligation over time. We also have a relationship with a financing company that can assist you, after qualification, with paying for your dental needs.
RESCHEDULING FEES
We are grateful to have a thriving practice and are often booking clients in excess of four weeks in advance. In addition, we pride ourselves on dedicating our undivided attention to our clients during their appointment. We also understand that our clients are up to great things and will sometimes have changes in their schedules.

We request at least 48-hour notice if you need to reschedule an appointment, except in emergency circumstances such as a car accident or severe illness. Should you provide less than 48-hours’ notice, we will make every effort to fill the time with a client who desires to come in sooner. If we are unable to fill the appointment, there will be a rescheduling fee, as indicated below. We also reserve the right to request payment for an appointment in advance.

Type of treatment	Rescheduling Fee
Regular perio-maintenance/prophy (teeth cleaning)	$150
New Client Experience	$150
Treatment w/Dentist totaling to $250 or less	$150 or cost of appointment if under $150
Treatment w/Dentist totaling $250 - $1500	$150 - $450
Treatment w/Dentist totaling $1500 or more	$500 - $750
Whitening	Cost of the treatment

If you accrue on an outstanding balance, and if it remains unpaid for 30 days, your account may be sent to a collection agency and report to the associated credit bureaus; in such event, you are responsible for any fees charged by the collection agency to collect your unpaid balance.

Please indicate your understanding and acceptance of the financial practices and authorization to charge the card you provided for rescheduling fees by signing below.
Client Signature*

Clear
Date*

MonthDayYear
Date
INSURANCE
While it is not necessary that you have dental insurance to be our client, if you do have dental insurance, we will help you get the most from that insurance. We will fill out your insurance forms for you and submit them on your behalf. The insurance company will then reimburse you directly in accordance with your policies' allowances. If you would like to have us assist you in this regard, you must provide us with the dental insurance name, ID number, group number, and insurance company's address and phone number. If you are not the subscriber on the insurance, we would need the name, date of birth, and social security number of that person.

Most insurance policies cover a significant portion of routine maintenance, such as teeth cleanings, but the amounts and services covered vary from plan to plan. The important question is whether your insurance allows you to choose your own dentist (this is called a PPO plan), or whether you have to see only dentists that are in your plan's network. (This is an HMO plan). As long as you have a PPO insurance plan, we can submit claims on your behalf.
INSURANCE INFORMATION
Name of Insured

First NameLast Name
Insured's Birth Date

MonthDayYear
Date
Subscriber ID Number
Insured's Group Number
Insurance Plan Name
Insurance Plan Phone

Area CodePhone Number
Insurance Plan Address

Street City State Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Employer Address

Street City State Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
CONSENT
I affirm that the information provided in my intake interview and documentation is complete and correct to the best of my knowledge. I understand that this information will be held in strict confidence under all applicable laws, and agree to promptly inform this office of any changes in my personal or medical status. In the event of a dispute regarding services or fees that the parties are unable to resolve, I agree that such dispute will be submitted to binding arbitration in accordance with American Arbitration Association rules, with each party bearing its own costs and fees, and irrevocably waive my right to have any dispute adjudicated by a court of law or jury. I consent to and authorize Dr. Ruhi Sangha, Dr. Praj Kamat, and staff to perform any and all dental diagnoses and any necessary treatment.
Client /Parent or Legal Guardian Signature *

Clear
If client is a minor, a parent or legal guardian must sign.
Name*

First NameLast Name
Date*

MonthDayYear
Date

Acknowledgment of Receipt of Privacy Practices Notice and Dental Material Fact Sheet
This document acknowledges that you have received a copy of
1. Notice of Privacy Practice
2. Dental Material Fact Sheet.
This document is not a contract, authorization, release, or consent form. This document will remain in your records.
From time to time we apprise our clients of events that may be of interest to them via email or mail. Please check here if you do NOT wish to be notified of such events.
I {whatIs152} Acknowledge that I have received a copy of the Notice of Privacy Practices and the Dental Material Fact Sheet.
Patient's Signature*

Clear
If client is a minor, a parent or legal guardian must sign.
Patient's Name*

First NameLast Name
Date*

MonthDayYear
Date
Client / Parent or Legal Guardian Signature*

Clear
If client is a minor, a parent or legal guardian must sign.
Patient's Name*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to Patient

New Patient Form

GETTING TO KNOW YOU

Please provide us with the following telephone numbers

Please provide an emergency contact person and contact information.

Financial Practices & Consent for Treatment

FINANCIAL PRACTICES

RESCHEDULING FEES

INSURANCE

INSURANCE INFORMATION

CONSENT

Acknowledgment of Receipt of Privacy Practices Notice and Dental Material Fact Sheet

DENTAL HISTORY

Please answer "Yes" or "No" to the following.

PERSONAL HISTORY

GUM AND BONE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS

MEDICAL HISTORY

DO YOU HAVE OR HAVE YOU EVER HAD: YES NO

ARE YOU

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATION YOU MAY BE TAKING.