New Patient Registration

Please thoroughly answer our health questions so that we may be of better service to you.

1. I understand the above information is necessary to provide patients with dental care in a safe and efficient manner.

2. I have answered all questions truthfully and to the best of my knowledge. I agree to notify the doctor of any dental or health changes at subsequent visits.

3. I authorize the doctor and/or staff to obtain x-rays, study models, photographs or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the patient's needs. I consent to be photographed before, during and after treatment. These photographs shall remain property of Dr. Eric Hwang and may be published in dental journals, office manuals and/or shown for educational purposes. l understand that my first name may be used with these photos for identification purposes.

4. l will be given the opportunity to discuss my treatment plan with the doctor prior to beginning any treatment.

5. I give my consent for the dental treatment, medication or therapy indicated on my treatment planned any other treatment deemed advisable as corollary to this treatment plan.

6. I understand that all information on this patient information form will be held in strict confidence and in accordance with all HIPAA rules and regulations.

7. I understand this practice has a 24-HOUR appointment cancellation policy. I understand that this practice must receive my appointment confirmation one working day in advance or my appointment time will be offered to another patient. I understand l will receive a courtesy message to reschedule my appointment. lf a second late notice cancellation occurs, I will receive a letter to politely remind me of the 24 HOUR cancellation policy.

8. lt is my responsibility to obtain all my previous dental x-rays and treatment records prior to the day of my first appointment to avoid charges created that will not be covered under my insurance coverage.

In accordance with the Federal Truth-in-Lending Act, the following policies apply in our office:

1. Payment is due at the time treatment is rendered or by previous financial arrangements.

2. ln the event my insurance company does not cover the entire balance of my account within 30 days from treatment date, I agree to pay the balance in full within 60 days of treatment date or by previous financial arrangements.

3. There is a forty-dollar ($40) charge on all returned checks, and a missed appointment fee of $60 if not cancelled within prior to the 24 hour window.

4. In the event of default, I agree to pay legal interest on the original indebtedness, to include any interest, any collection costs, and related attorney's fees.