• PATIENT INFORMATION

  • Welcome to our office. We appreciate the confidence you place with us to provide dental services.
    To assist us in serving you, please complete the following forms. The information provided on
    all forms are important to your dental health.

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  • If you are a new Patient:

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  • Office Policy

  • We currently only take Cash, Check, VISA, MC, AMX, & CareCredit for payment.

    I hereby authorize payment directly to Dr. Brandon Atkinson, from my group insurance benefits. I
    understand that I am responsible for all costs of dental treatment and/or insurance co-pays.

    Appointment Policy: We ask that you provide us with at least 48 hours notice if you need to cancel your
    appointment. We recognize that there are times when urgent situations require last minute appointment
    cancellations. We reserve time especially for you and with sufficient notice, we can fill that time. We strive to
    provide you the best dental care possible and appreciate your efforts in giving your dental appointments the
    priority they need. A $75 fee will be assessed for any cancelled appointments with less than 24 hour notice.

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  • ACKNOWLEDGEMENT 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:

    • Provider and coordinate my treatment among a number of, healthcare providers who may be involved in treatment directly and indirectly.
    • Obtain payment from third-party payors for my health care services.
    • Conduct normal health care operations such as quality assessment and improvement activities.

    I have been informed of my healthcare provider’s Notice of Privacy Practices ( located behind paperwork on clipboard) which contains a complete a more complete description and disclosures of my PHI – Protected Health Information. I have been given the right to review and receive a copy if I chose.

    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 you are bound to abide by such restrictions.

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