www.manchesterdental.net - New Patient Form

New Patient Form
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Social Security Number
Whom may we thank for referring you to our office?
Responsible Party Information
Name*

First NameMiddle NameLast Name
Marital Status
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party Contact Information
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
E-mail Address*
example@example.com
Social Security Number
Date of Birth

MonthDayYear
Relationship to patient
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Spouse's Information

(Only if spouse's insurance is being used)
Social Security Number
Date of Birth

MonthDayYear
Cell Phone Number
Please enter a valid phone number.
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Acknowledgement of Receipt of Notice of Privacy Practices
I {patientName} have received a copy of this office's Notice of Privacy Practices.
Appointment cancellation Policy
We strive to render excellent dental care to you and the rest of our patients. We respect your time and make every effort to keep you from waiting. As a result, your appointment time in this office is reserved exclusively for you.
Our policy is as follows:
We require that you give our office 24 hours' notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $50.00 will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled, nor can records be transferred without the payment of this fee.

Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment, and the $50.00 cancellation fee will be charged.

If you have any questions regarding this policy, please let our staff know, and we will be glad to clarify any questions you have.

We thank you for your patronage.
I have read and understand the Appointment Cancellation Policy of the practice, and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.
I {patientName} have received a copy of Manchester Dental's Cancellation Policy.
Signature of Patient*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

New Patient Form

Responsible Party Information

Responsible Party Contact Information

Spouse's Information

Acknowledgement of Receipt of Notice of Privacy Practices

Appointment cancellation Policy

Our policy is as follows:

Medical History

Do you have or have you had any of the following diseases or conditions?

Assignment of Insurance Benefits