www.commonsensefamilydentistry.com - Patient Information Form

Patient Information Form
Name

First NameLast Name
Preferred Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
If "Other" Please Explain
Marital Status
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
May we send Text Reminders?
Employer Name
May we call you on your cell phone?
Emergency Contact
Emergency Contact Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party Information
Same as Above?
If not please fill out the information below:
Name

First NameMiddle NameLast Name
Gender
Marital Status
Date of Birth

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name
Is the responsible party a patient of Common Sense Family Dentistry?

Insurance Information-all information refers to Insured Member
Name
Date of Birth

MonthDayYear
Social Security Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name
Relationship to Patient
If "Other" Please Explain
Is the insured a patient of Common Sense Family Dentistry?
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our office?
Insurance Authorization
Signature on File
1. I authorize the use of this form on all my insurance submissions.
2. I authorize release of information to all my insurance carriers.
3. I understand that I am responsible for my bill, regardless of whether insurance pays or not.
4. I authorize my doctor to act as my agent in helping me to obtain payment from my insurance carriers. Any amounts not paid by insurance within 60 days of the service date will be paid by me.
5. I authorize payment directly to my doctor for services.
6. I permit a copy of this authorization to be used in place of the original.
Consent for Treatment
1. I hereby authorize Dr. Scott Stucki and/or his associates, and team members to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of (name of patient) ’s dental needs.
2. Upon such diagnosis, I authorize Dr. Scott Stucki and Associates to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf or that of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I agree to pay all costs of collection including a 33.3% collection fee, attorney fees, court costs and a finance charge (interest) at the rate of 1 ½% (18% APR) with a minimum charge of $5. If required, I also understand a check of my credit history may be made.

5. I understand there is a $50 fee for missed appointments and for appointments cancelled with less than 48 hours notice.

6. There is a 3.5% electronic fee for all credit card transactions. (Subject to industry changes)
Parent/Responsible Party Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship

HIPAA Release Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Release of Information-I authorize the release of information including the diagnosis, records, examination(s) rendered to me and claims information. This information may be released to: (please list none if you don't want your information shared).
This Release of Information will remain in effect until terminated by me in writing.
MESSAGES
Please Call
If unable to reach me
Other method of reaching me
The best time to reach me is
(Day) between (Time)
Patient's Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Photograph and Publicity Release Form
Name

First NameLast Name
I, {name} give D. Scott Stucki, DDS and Common Sense Family Dentistry permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of D.Scott Stucki, DDS and Common Sense Family Dentistry activities. I agree that D. Scott Stucki, DDS and Common Sense Family Dentistry have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with D. Scott Stucki, DDS and Common Sense Family Dentistry missions. These uses include, but are not limited to, illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, social media and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release D. Scott Stucki, DDS and Common Sense Family Dentistry and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.

I have read and understood this consent and release.

I give my consent to D. Scott Stucki, DDS and Common Sense Family Dentistry to use my name and likeness to promote D. Scott Stucki, DDS and Common Sense Family Dentistry program, its fiscal agent, and/or their activities.
Patient's Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent /Legal guardian (if under 18 years old)
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Notice of Privacy Practices
The information given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes.
Patient's Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Patient Information Form

Emergency Contact

Responsible Party Information

If not please fill out the information below:

Insurance Information-all information refers to Insured Member

Insurance Authorization

Signature on File

Consent for Treatment

HIPAA Release Form

MESSAGES

The best time to reach me is

Photograph and Publicity Release Form

Notice of Privacy Practices