Patient Information
Name
*
First Name
Middle Name
Last Name
Status
Married
Single
Minor
Male
Female
Social Security
State Driver’s License#
*
Address
*
Street Address
Street Address Line 2
City
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State
Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Telephone: Home
Please enter a valid phone number.
Format: (000) 000-0000.
Telephone: Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
E - Mail
*
example@example.com
Name Of Employer
If Full Time Student, School Name
Person Responsible For Account – Please Check One:
*
Patient/Self
Guardian
Spouse
Parent
Insurance Information
Do you have Dental Insurance Coverage?
*
Yes
No
Primary Insured Or Responsible Party
Primary Insured Name
First Name
Middle Name
Last Name
Street
City
State
Zip
Home
Work
Cell
E-Mail
Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient
Employer
DENTAL INS. CO.
SS#
Subscriber #
Group #
Secondary Insured Or Responsible Party
Name
First Name
Middle Name
Last Name
Street
City
State
Zip
Home
Work
Cell
E-Mail
Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient
Employer
DENTAL INS. CO.
SS#
Subscriber #
Group #
Personal Contact In Case of Emergency
Name of Personal Contact In Case Of Emergency
*
Address
City/State/Zip
Telephone #
*
Has any member of your family ever been treated in our office?
Yes
No
Whom may we thank for referring you to our office?
AUTHORIZATION AND CONSENT FOR TREATMENT
I AUTHORIZATION AND CONSENT FOR TREATMENT
*
1. I hereby authorize payment directly to Ban R. Barbat, DDS-PC of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize Ban R. Barbat, DDS-PC to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or health professionals.
2. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of dental needs.
3. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
4. I understand that if I decline to undergo treatment, delay treatment, or fail to keep my appointment (s), I accept that there may be permanent irreversible damage to my dental health.
5. I agree to the use anesthetics, sedatives and other medication, as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
6. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
Date
*
-
Month
-
Day
Year
Date
Patient’s Signature
*
Parent/Responsible Party’s Signature
ACKNOWLEDGMENT OF PRIVACY PRACTICES
*
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers for my health care services. Conduct normal health care operations such as quality assessment and improvement activities. I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Date
*
-
Month
-
Day
Year
Date
Patient's Signature
*
Dependent family members also covered by this acknowledgement:
APPOINTMENT CHANGES
*
I understand that appointments are reserved exclusively for me. I accept that changes to the time and/or date must be made with a minimum notice of 2 business days and that failure to do so may lead to a $50 cancelation fee.
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