Pylant Periodontics - Patient Registration

Patient Information
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

MaleFemale
Status

MarriedSingleChild/MinorOther
Social Security #
Phone Number - Cell
Phone Number - Home
Phone Number - Work
Email*
May our office confirm the appointment via email and text?

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
EMERGENCY CONTACT
Name

First NameLast Name
Relationship
Phone Number
Whom may we thank for referring you to our practice?

Another patient, friendAnother patient, relativeDental OfficeInternet SearchPhysician OfficeWorkOur WebsiteOther
Name of Person or Office Referring You to Our Practice
Patient Employment Information
Employer Name
Occupation
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party Information

The following questions relate to the person who is the RESPONSIBLE PARTY for the above named patient.
Is the patient also the Responsible Party?

YesNo
Responsible Party: Relationship to Patient

SpouseParentOther
Name

First NameLast Name
Gender

MaleFemale
Status

MarriedSingleChildOther
Social Security #
Phone Number - Cell
Phone Number - Home
Phone Number Work
Does the responsible party have the same address as the patient?

YesNo
Address

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party: Employment Information
Employer Name
Occupation
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Information
Is the patient also the primary person insured?

YesNo
Patient's Relationship to Insured

SpouseChildOther
Name of Insured

First NameLast Name
Insured's Birth Date

MonthDayYear
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Employer Name
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company
Insurance ID#
Insurance Group #
Office Policies

Please read our office policies carefully.
Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
Insurance Statement

Patients who have dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's dental insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. With healthcare rapidly changing, it would be impossible for us to keep up with thousands of different plans. The patient is responsible for understanding their own policies. We will do everything we can to assist with that understanding but you; the patient must ultimately be responsible for understanding your policy. We are an OUT-OF-NETWORK provider. We do not accept contracted insurance plans. We do accept insurance plans that allow the patient the right to choose their own dentist.
Financial Policy

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. Payment for services is expected at the time services are rendered unless prior arrangements have been made. We accept Visa, MasterCard, Discover, checks and cash. We offer a 3% cash discount on balances over $500.00 and we offer payment plans, some without interest, through outside financial sources. There is a $30.00 charge for returned checks.
Contact Statement

We know how busy you are and we understand your time is valuable. Your satisfaction is our top priority and we try our best to run on schedule and trust you will too. Dr. Pylant requires confirmation of your appointment so we know to expect you. In the event you have to cancel, we ask for a 24 hour notice. 48 hour notice of cancelation is required on appointments (4) hours and longer. A charge of $25 or more (depending on length of appointment missed) may be assessed for "no shows".
I grant permission to you or your assignee to telephone me at home, work or by cell phone to discuss matters related to this form.

YesNo
I grant permission to you or your assignee to leave messages about my appointments at my home, work, cell phone or email.

YesNo
Privacy Statement

**We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. I grant my permission to you or your assignee, to provide the following family member (s), friend or other person right of disclosure to my healthcare records including discussion of payment on my account: This agreement will remain in effect indefinitely unless I rescind permission.

Who do you want to give permission to access your medical information?

	Full Name	Relationship
1.
2.
3.

Signature of Patient, Parent or Guardian*

Clear
Name of Signer*
Today's Date

MonthDayYear
Date
Should be Empty:

Patient Information

Patient Employment Information

Responsible Party Information

Responsible Party: Employment Information

Insurance Information

Office Policies