07-2023 BOPD New Patient Forms

Confidential Patient Information
Thank you for filling out our online new patient paperwork! If using insurance, you will need the insured party's insurance information (SSN, insurance company name, insurance ID# and group#) to complete the form. Please bring a copy of your photo ID and insurance card to the appointment.
Are you visiting our office for Pediatric Dentistry, Orthodontics, or both?*

Pediatric DentistryOrthodonticsBoth
Patient's Name:*

First NameLast Name
Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Date of Birth:*

MonthDayYear
Date
Patient's SSN:*
Gender*

MaleFemale
If patient is a minor, list parent or guardian's name:

First NameLast Name
Who may we thank for referring you to our office?*

Confidential Responsible Party Information
Name:*

First NameLast Name
Marital Status:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address:*
Cell Phone:*
Home Phone:
Social Security #:*
Date of Birth:*

MonthDayYear
Date
Relationship to Patient:*
Employer:*
Occupation:*
Spouse's Name (or N/A):*
Relationship to Patient:
Social Security #:
Date of Birth:

MonthDayYear
Cell Phone:

Insurance Information
Will you be using insurance?

YesNo
Policy Holder's Name:*

First NameLast Name
Policy Holder's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*

MonthDayYear
Policy Holder's Social Security #:*
Employer:
Insurance Company:*
ID #:*
Group #:*
Do you have dual coverage?*

YesNo
If yes:
Please provide the name of your secondary dental insurance plan

Emergency Information
Emergency Contact:*

First NameLast Name
Phone Number:*
Email:*
Relationship to Patient:*
Signature (Parent's signature if minor):*

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Authorize Change Treatment
Patient Name:*

First NameLast Name
Patient's DOB:*

MonthDayYear
Date
Patient Phone #:*
Please enter a valid phone number.
I, Parent/Legal Guardian Name the parent/guardian of, Patient's Name authorize the following Person/People to bring my child/children to any future dental appointments, as well as making any necessary decisions regarding my child's dental treatment. This may include the use of a papoose blanket or any other treatment deemed necessary in the best interest of the child. I fully understand these changes may include adjustments to the treatment plan which may have an effect on additional costs that will be required to be paid in full on the day of service as discussed when the initial treatment plan was presented and signed.

By signing below, all parties listed are aware of the possibility of having the authority to make a decision to change treatment and pay additional cost. We invite your questions concerning the possibility of change in treatment. By signing below you acknowledge that you have read this document, understand the information presented, and we have had all your questions answered satisfactorily.
Authorized Parties:*
Signature*

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PRIVACY CONSENT
This form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use this form. Prior to commencing your orthodontic treatment, you should review, sign and date this form. Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure. You have the right to review our office’s privacy notice prior to signing this consent, a copy of which was given to you with this Consent. You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request. We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice. You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent. Thank you for your cooperation. Please let us know if you have any questions.*

I acknowledge receipt of this form.
Signature (Parent's signature if minor):*

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Date:*

MonthDayYear
Date

PATIENT PHOTO/VIDEO RELEASE
Patient Name:*

First NameLast Name
The above named patient (or parent/legal guardian) of Boerne Orthodontics & Pediatric Dentistry, consents to: (i) have the patient's likeness and/or voice recorded on a video, audio, photographic, digital, electronic or any other medium; (ii) the use of their name in connection with such recordings; and (iii) the use, reproduction, exhibition, and/or distribution of their name and such recordings in any medium (e.g. print publications, video, internet, etc.) for promotional, advertising, education, and/or other lawful purposes. The patient (or parent/guardian) releases and waives any claims or rights of ownership or compensation regarding such uses and understands that all such recordings shall remain the property of Boerne Orthodontics & Pediatric Dentistry.*

I authorize the recording and use of photo/videos as outlined aboveI DO NOT authorize the recording and use of photos/videos as outlined above
Signature (parent/guardian if patient is a minor):*

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Date:*

MonthDayYear
Date

FINANCIAL AGREEMENT
Thank you for selecting us as your personal dental and orthodontic care team. To promote a long-term, mutually satisfying relationship, we would like to explain our office policy regarding treatment, insurance, appointments and fees. Please read this carefully and ask any questions or bring up concerns before treatment is rendered.

Treatment:
We will always recommend treatment based on optimal care, and not on insurance benefits. We will, however, always offer alternate treatment options that may better fit your health care budget.

Insurance:
As a courtesy to you, we will submit all insurance claims on your behalf, and any follow-up processes that may be necessary. Our staff prides itself on helping our patients maximize their benefits, and are always available for questions. Ultimately, the patient is fully responsible for the charges for the treatment rendered. Your Insurance may not cover the services or may only partially cover them and any estimate given by this office is considered a guideline until insurance payment is received and the patient's account is reconciled. The office makes no guarantee of the actual payment by your insurance company. At no time will we change treatment codes or dates of service to manipulate your insurance benefits. This is insurance fraud.

Missed Appointments:
When we schedule your appointment, this time is reserved exclusively for you. When you fail to notify us of your inability to keep the appointment, another patient in need of care is unable to receive treatment. We request that you give us one business day’s notice when you realize you cannot keep an appointment. A fee of $50.00 per hour scheduled may be charged for a broken appointment.

Payment at time of service:
We accept cash, personal checks, MasterCard, Visa, Discover, American Express, and HSA/FSA cards. In addition, we offer Care Credit and Lending Point for those requiring extended payment plans. We will collect any deductible or estimated copay at time of service.
*

By signing below, I understand that I am responsible for all fees incurred for dental treatment and agree to pay according to the option I have chosen. Additional charges may occur if the account is turned over for collection.
Signature (parent's signature if minor)*

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Date*

MonthDayYear
Date
Patient's Name*
Parent/Guardian Name (if minor)
Should be Empty:

Confidential Patient Information

Confidential Responsible Party Information

Insurance Information

Emergency Information

Dental History

Medical History

Authorize Change Treatment

PRIVACY CONSENT

PATIENT PHOTO/VIDEO RELEASE

FINANCIAL AGREEMENT