New Patient Information

Full Name

First NameLast Name

Birth Date

MonthDayYear

Social Security Number

Required if we will be submitting dental insurance claims

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Mobile

Area CodePhone Number

How did you find out about us?

e-mail

Whom Should We Thank for Referring You?

Please enter family member, friend or co-worker's name!

Emergency Contact Information

First NameLast Name

Emergency Contact Number

Area CodePhone Number

Relationship

Employer Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Dental Insurance Provider

Group Number

Policy Subscriber Name

Subscriber ID

Policy Subscriber Date of Birth

MonthDayYear

Do you have a secondary dental insurance plan?

Please indicate secondary insurance provider

Are you currently under a physician's care?

Physician's Phone Number

Area CodePhone Number

Physician's Name

First NameLast Name

When was your last visit?

Reason for visit?

Do you have allergies to any of the following?

Please list all medications you are currently taking (if none, please write "NONE")

Cardiovascular

Genitourinary

Endocrine & Neurological

Blood Disorders/Joint Diseases

Respiratory & Miscellaneous

Please list all medications you are currently taking (Answer "NONE" if you do not take meds)

Purpose of initial visit

Previous Dentist's Name

First NameLast Name

Previous Dentist's Phone Number

Area CodePhone Number

When was your last cleaning?

Have you had x-rays within the last 6 months?

Are you currently experiencing discomfort in your mouth?

On a scale of 1 to 10, how bad is this discomfort?

Do you have any of the following?

Are you experiencing any of the following symptoms?

Are you unhappy with the appearance of your teeth?

Are you unhappy with your breath at times?

Please use this space to provide additional information that you would like the doctor to know about

Informed Consent

I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services and that I am financially responsible for payment in full of all accounts. By checking this box and digitally signing this form, I revoke all previous agreements to the contrary and agree to be fully responsible for payment of dental services provided. I understand that a service charge of 22% per annum will be applied on any unpaid balance for completed procedures on all accounts exceeding 30 days, unless written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care can only be extended for a period of 3 months from the date of my initial examination.

We are out-of-network with all major insurance companies. As a courtesy, we will submit insurance claims to your insurance company for reimbursement. Co-pays and/or full-payment may be required at the time services have been rendered.

Please understand that your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. Regardless of insurance status, you are ultimately responsible for the balance of your account. To avoid unecessary finance charges, payment in full for completed procedures is greatly appreciated.

Insurance Payments

We reserve specific time slots for each and every patient and we kindly request a notice of at least 48hrs should you need to reschedule your appointment.

A fee of $150 per hour appointed will be incurred for the 1st missed/canceled appointment, or appointment canceled with less than 48 hrs notice.

A fee of $250 per hour appointed will be charged for 2 or more missed/canceled appointments, or appointment cancellations with less than 48hr in advance notice; to reappoint, full payment for treatment originally scheduled must be made in advance.

A fee of $500 per hour appointed will be incurred for missed surgical appointments, or with less than 48 hours advance notice.

If you are running more than 20 minutes late we reserve the right to reschedule your visit and a 'broken appointment' fee of $150 will be applied to your account.

Acknowledgement of Privacy Policy

With my permission, Core Smiles may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). I have the right to review the Notice of Privacy Practices prior to signing this consent. Core Smiles reserves the right to revise the Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer. With my permission, Core Smiles may call my home or other designated locations and leave a message on voice mail, email, text message, or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my permission, Core Smiles may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. Additionally, with my permission, Core Smiles may use photographs, study models and other treatment records as documentation for lectures and learning objectives in an educational setting. At no point in time will my identity--visually or by name--be disclosed. I have the right to request that Core Smiles restricts how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this, I am allowing Core Smiles to use and disclose my PHI for TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent.

Signature

Our Credit Card on File Program is intended as both an advantage to you and to our office. You will no longer have to write out and mail us checks or call us to provide a form of payment over the phone. This system will greatly decrease the number of statements that we have to generate and send out thereby benefitting everybody in helping to keep the cost of health care down. You will be asked for a credit card at the time you check in and the information will be held on our secure server. You will always have the option to pay fees using another payment method, if you do so in a timely manner. Charges to the credit card on file will be determined as follows:

Copays/Self Pay Charges – Copays are due on the date of service, per your contract with your insurance company. Self-pay charges are due on the date of service, per your agreement with our office. You may present another method of payment prior to, or at the time of service. If another method of payment is not offered by the date of service, your credit card will be charged.

Coinsurance and/or Deductibles – These amounts are determined after your insurance company has completed processing your claim. If a balance remains on your account after we receive your insurance check, your credit card will be charged for any balance due.

Late Cancellation or No Show Charges – These charges are generated by your provider if you fail to show up for a scheduled appointment or if you do not give adequate notice for canceling an appointment. If you incur such a charge, your credit card will be charged for any balance due.

This will not compromise your ability to dispute a charge or question your insurance company’s determination of payment. PLEASE NOTE: If the credit card provided expires, becomes invalid, or lacks sufficient funds, it will be required that you update your credit card on file information immediately and/or pay your balance in full in order to reschedule with your provider.  

Name

First NameLast Name

Date of Birth

mm-dd-yyyy

Until further notice, I authorize Core Smiles to charge balances on this account to the following credit card:

Cardholder Information

First NameLast Name

Card Number

Include Dashes

Expiration Date

mm-dd-yyyy

Cardholder Signature

3 or 4 Digit Security Code

For Amex, use 4 digit code on front of card

Cardholder Address

Street Address

CityState

Zip Code

Today's Date

Date

MEDICAL HISTORY

Do you have a history of the following? (please check all that apply)

DENTAL HISTORY

FINANCIAL POLICY

CANCELLATIONS and MISSED APPOINTMENTS

PRIVACY POLICY

Credit Card on File Authorization