Hometown Dental Richmond Patient Information

Hometown Dental Richmond Patient Information
About You
Full Name:*

First NameMiddle NameLast Name
Birthdate:*

MonthDayYear
Date
Social Security Number:*
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Work Phone
Please enter a valid phone number.
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Person Responsible
Is the person responsible for this account different than the patient? If no please skip the rest of the section.*

YesNo
Name

First NameLast Name
Relationship to Patient
Employer
Birthdate

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.

Emergency Contact
Name*

First NameLast Name
Relationship*
Phone*
Please enter a valid phone number.
In case of an emergency, I hereby grant permission to release appointment or medically related information concerning the patient to the above person.

Dental Insurance Information
Please check this box and skip this section if you do not have dental insurance!*

I do not have dental insurance.
Primary Dental Insurance Company
Policy Holder Name
Policy Holder Birthdate

MonthDayYear
Date
Policy Holder SS#
Group Number
Company Phone
Please enter a valid phone number.
Company Fax
Secondary Dental Insurance Company
Policy Holder Name
Policy Holder Birthdate

MonthDayYear
Date
Policy Holder SS#
Group Number
Company Phone
Please enter a valid phone number.
Company Fax

Payment Policy
Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequencies, age restrictions, deductibles and maximums which are your responsibility. Please contact your insurance company for a detail of your benefits. Your insurance company and your benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.

I understand that I am responsible for payment of services rendered by Hometown Dental and that payment is due the day of service. I understand that I am also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the Hometown Dental to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Signature*

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Date*

MonthDayYear
Date

Cancellation and No Show Policy
When our office schedules your appointment, we reserve a unique reservation where we set aside time, order materials and make special arrangements to be ready for your visit.

We understand that situations arise in which you may cancel your appointment. We therefore request that you must cancel your appointment that you provide at least 24 hours notice. This will enable another person who is waiting for an appointment to be scheduled in that appointment slot. With cancellations made less than 24 hours prior, we are unable to offer that slot to other people. Appointments which are cancelled with less than 24 hours notification may be subject to a $50.00 cancellation fee.
Patients who do not show up for their appointment without a call to the office to cancel will be considered as a “No Show”. Patients who No-Show three (3) or more times in a 12 month period, may be dismissed from the practice thus they will be denied any future appointments. Patients may also be subject to a $50.00 office appointment No Show fee.

The cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment.
We understand that special unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance may be waived, but only with management approval.

Please sign that you have read, understand and agree to this Cancellation and No Show Policy.
Patient Name (please print)*
Date*

MonthDayYear
Date
Signature of Patient or Patient's Representative*

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Authorization
I understand that a copy of this office's privacy practices can be found on their website or requested from the office.
Signature*

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Date*

MonthDayYear
Date
I affirm that the information I have given is correct to the best of my knowledge. All information herein will be held in the strictest confidence and it is my responsibility to inform Hometown Dental of any changes in my medical status. I authorize dental staff to perform the necessary dental services I may need, including x-rays, photographs, study models, or any aids deemed appropriate to make a thorough diagnosis of my dental needs.
Signature*

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Date*

MonthDayYear
Date
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Hometown Dental Richmond Patient Information

About You

Person Responsible

Emergency Contact

Dental Insurance Information

Payment Policy

Cancellation and No Show Policy

Dental History

Medical History

Authorization