PATIENT INFORMATION

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.
Sex:

M F
Preferred Name:
Patient Name:
Date of Birth:

Month Day Year
Age:
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell:
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Email:
example@example.com
Spouse’s Name:
Phone #
Please enter a valid phone number.
Emergency Contact:
Please enter a valid phone number.
Emerg. Phone # (other than spouse):
Please enter a valid phone number.
Primary Dental Insurance:
Group #:
Employer:
Subscriber’s Name:
Date of Birth:

Month Day Year
Date
INS ID #:
Secondary Dental Insurance:
Group #:
Employer:
Subscriber’s Name:
Date of Birth:

Month Day Year
Date
INS ID #:
If you are a new Patient:
Name of previous Dentist:
Date of last visit to Dentist:

Month Day Year
Date
Referred to us by:

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.
I have read and understand this policy:

Clear
Date

Month Day Year
Date

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.
Patient Name
Patient Signature

Clear
Date

Month Day Year
Date
Relationship to Patient
Dependent Family members also covered by this Acknowledgement:
We were unable to obtain written acknowledgement of our Notice of Privacy Practices due to:
Additional Disclosure Authority:
(specific instructions per patient on disclosures and concluded discussion with staff.)
Patient Signature

Clear
Staff Member Signature

Clear
Date

Month Day Year
Date
Date

Month Day Year
Date
Should be Empty:

PATIENT INFORMATION

If you are a new Patient:

Office Policy

ACKNOWLEDGEMENT OF PRIVACY PRACTICES