www.lifesmilesdentalcare.com - New Patient Form

New Patient Form

We would like to get to know you better!
Name*

First NameLast Name
SS #
Gender*
Address*
Street, City, State, Zip
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
E-mail Address*
example@example.com
Date of Birth*

MonthDayYear
Occupation
Employer
Parent or Spouse’s Name
Their Phone Number
Please enter a valid phone number.
Who may we thank for referring you?
Emergency Contact
Person to Contact in case of emergency*
Phone Number*
Please enter a valid phone number.
Person responsible for dental investment
For dependents 18 years and older that are covered under parent's insurance, we will need their student status for insurance processing.
Student Status :
Full Time Total Semester Hr’s
Part Time Total Semester Hr’s
For Insurance Purposes
Name of policy holder
Date of Birth

MonthDayYear
Relationship to Patient
SS #
Member I.D.
Employer
Insurance Company
Ins. Company Phone Number
Please enter a valid phone number.
Group Number
HIPAA Compliance Statement
Your health information may be used in our office to conduct scheduling and coordination of care between the doctor, dental assistant, hygienist, business office staff, and other dental specialists that are involved in your care. We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. Your health information may be reviewed during the routine process of certification, licensing, credentialing activities, or auditing for quality assurance.

Communication with our patients in an important part of our philosophy. We prefer to communicate with you directly, but we may incorporate the use of phone or text messages, emails, postcards, and letters. We will make every effort to respect your privacy and honor your request for confidentiality. If you have special needs in regards to privacy issues, please put them in writing for the office so that we may address your concerns.
Cancellation Policy
24 hours notice is required for any cancellations or changes to your scheduled appointments. If we receive less than 24 hours notice, a $75 fee will be applied to your account.
Financial Information
I have read and truthfully answered the above questions to the best of my knowledge. I authorize the doctor and/or his staff to release all information necessary to secure payment of my benefits from my insurance company.

I understand that fees may vary at the time of service due to the extent of treatment. Fees are estimates only and are not a guarantee of payment by my insurance company. I understand that the payment of this account is my responsibility, regardless of the amount my insurance company reimburses before or after payment in made.
Patient Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear

New Patient Form

Emergency Contact

For dependents 18 years and older that are covered under parent's insurance, we will need their student status for insurance processing.

Student Status :

For Insurance Purposes

HIPAA Compliance Statement

Cancellation Policy

Financial Information

Medical History

Please select (Yes) or (No) for any of the following which may apply to you now or in the past

Dental History