PLD New Patient Form

PROFESSIONAL LANE DENTAL
102 Professional Lane
Dothan, AL 36303

NEW PATIENT FORM

Welcome to our practice! We are delighted that you have chosen our office to assist you in achieving your dental needs. Your dental health is very important to us. So we may provide you with exceptional dentistry, we need some important information about you.

All areas notated with the red * must be completed.

We now accept Credit Card payments via Clover.

AGREEMENT TO PAY:

You will be expected to pay deductibles and co-pays at the time of service. We accept cash, checks, credit cards & Care Credit.

The undersigned accepts the fees charged as a legal and lawful debt and agrees to pay said fees, including any/all collection agency fees, (33.33%), attorney fees and/or court fees, if such be necessary.

You agree, in order for us to service your account or to collect monies you may owe, PROFESSIONAL LANE DENTAL and/or our agents, may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and agree that PROFESSIONAL LANE DENTAL, its employees and/or agents may contact me/us as described above.

Agree

Full Signature Required For Agreement To Pay Signature*

Broken Appointments Fee

Appointments that are canceled with less than 24-hour notice may be subject to a $35.00(hygiene)/$50.00(dentist) broken appointment fee.

Agree To Broken Appointment Fee

Agree

Initial Broken Appointment Fee*

Deductibles and Co-Payments

All deductibles and co-payments are due on the day of treatment unless prior arrangements have been made with the Office Manager.

Agree To Deductibles and Co-Payments

Agree

Initial Deductible and Co-Payments*

PROFESSIONAL LANE DENTAL PRIVACY PRACTICES
To proceed you must review and agree to our privacy practices below.

By checking the box (Below Privacy Policy) You are agreeing that you have read and agree to the Privacy Practices.*REQUIRED*

Click Here To Read Privacy Policy

Agree To Privacy Policy*

Agreed

I have Read And Agree With The Privacy Policy*

Todays Date*

Date

Patient Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Home Phone

Your Cell Phone

Your Work Phone

Your Email*

example@example.com

Preferred Method of confirming Appts - Check one*

HomeCellWorkEmail

Date Of Birth*

Date

Patient Gender*

MaleFemale

Marital Status*

MarriedSingle

Referred By

Are You Employed*

YesNo

Employer*

Employer Phone*

Emergency Contact*

Emergency Contact Phone*

Reason for visit*

Date Of Last Dental Exam

Date

Date Of Last X-Rays

Date

HAVE YOU HAD ANY UNFAVORABLE DENTAL EXPERIENCES AND/OR DO YOU HAVE ANY DENTAL FEARS?

IF SO, DESCRIBE

PERSON RESPONSIBLE FOR ACCOUNT*

SelfOther Person

Name Of Responsible Person*

First NameLast Name

Date Of Birth Of Responsible Person *

Date

Relation To Patient*

Address Of Responsible Person*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number Of Responsible Person*

Cell Number Of Responsible Person*

Work Number Of Responsible Person*