New Patient Forms

HEALY DENTAL CARE

JAMES R. HEALY D.D.S.

548 12th Street

Ogden, Utah 84404
PATIENT INFORMATION
Date

MonthDayYear
Name*
Birth Date*

MonthDayYear
SS Number
Home Phone
Work
E Mail Address
example@example.com
Cell*
Address*

Address

Street Address Line 2

CityState

Zip
Drivers License #
State
IN CASE OF EMERGENCY
Nearest relative not living with patient*
Address*

Address

Street Address Line 2

CityState

Zip
Home Phone
Day Phone*
Friend or neighbor*
Phone*
Address*

Address

Street Address Line 2

CityState

Zip
PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT( If different than patient)
Name
Birth Date

MonthDayYear
SS Number
Employer
Work Phone
Spouse
Birth Date

MonthDayYear
SS Number
Employer
Work Phone
Address

Home Address

Street Address Line 2

CityState

Zip
Home Phone
INSURANCE INFORMATION
1st Insurance Co.
Policy #
Address*
Group #
2nd Insurance Co.
Policy #
Address*
Group #
FINANCIAL AGREEMENT
5% Discount for cash at time of treatment
Insurance Co payment due at time of service
How will you be handling your account Cash, Check or Credit Card?
How were you referred to our office?
I agree to pay account in full within 30 days of statement I agree to pay 11/2% service charge per month on any past due balance plus cost of collection and reasonable attorney fees I also authorize release of any information relating to claims I understand that, where appropriate, credit bureau reports may be obtained
Signature*

Clear
(Patient or legal guardian or parent of patient)
Date*

MonthDayYear

FINANCIAL POLICY
Healy Dental Care
James R. Healy D.D.S
548 12th Street
Ogden, UT 84404,(801) 394-0808
To our Valued Patients

Today in our world of rising prices we are trying to keep our fee increases to a minimum by implementing new payment policies. This will help reduce our overhead, thus passing along the savings to our patients.

As in the past, and as a favor to you, we will continue to file your Insurance Claims. Our office will be implementing the following payment policies. Please initial each box.
1. Patients that do not have Dental Insurance will be required to pay ALL FEES IN FULL AT THE TIME SERVICES ARE RENDERED.*
2. Patients having Dental Insurance will be required to pay their DEDUCTIBLE and ESTIMATED PORTION of the fees at the time services are rendered You will also be responsible for any balance remaining after the Insurance Co. has paid the claim.*
3. A 5% Professional Discount To be eligible for the 5% discount, all fees must be paid in full on the day of service with check, cash, Master card, Visa or Discover card.*
4. While the filing of Insurance claims is a courtesy that we extend to our patients, WE MUST EMPHASIZE that as dental care providers. our relationship is with the patient, not with the Insurance Co. If we do not receive payment from your insurance company within 60 (sixty) days, payment becomes your responsibility.*
5. Your appointment time in this office is reserved just for you, because you are important to us. A $44 (forty four) fee will be charged for any appointment cancelled or rescheduled without one working days notice. Please help us to avoid charging this fee by keeping your scheduled appointment.*
I have read the above policies and agree to abide by them.
Date*

MonthDayYear
Signed*

Clear
Should be Empty:

PATIENT INFORMATION

IN CASE OF EMERGENCY

PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT( If different than patient)

INSURANCE INFORMATION

FINANCIAL AGREEMENT

MEDICAL HISTORY

ARE YOU ALLERGIC TO:

INFORMED CONSENT

FINANCIAL POLICY

Healy Dental Care
James R. Healy D.D.S
548 12th Street
Ogden, UT 84404,(801) 394-0808

PATIENT INFORMATION

IN CASE OF EMERGENCY

PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT( If different than patient)

INSURANCE INFORMATION

FINANCIAL AGREEMENT

MEDICAL HISTORY

ARE YOU ALLERGIC TO:

INFORMED CONSENT

FINANCIAL POLICY

Healy Dental CareJames R. Healy D.D.S548 12th StreetOgden, UT 84404,(801) 394-0808

Healy Dental Care
James R. Healy D.D.S
548 12th Street
Ogden, UT 84404,(801) 394-0808