09-2024 BOPD New Patient Forms

2nd Patient's Name:*

First NameLast Name
2nd Patient's Address*

Same as Patient 1New address
2nd Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Patient's Date of Birth:*

MonthDayYear
Date
2nd Patient's SSN:*
2nd Patient's Gender*

MaleFemale
Do you have additional patient information to enter? E.g. additional children.*

YesNo

3rd Patient's Name:*

First NameLast Name
3rd Patient's Address*

Same as Patient 1New address
3rd Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3rd Patient's Date of Birth:*

MonthDayYear
Date
3rd Patient's SSN:*
3rd Patient's Gender*

MaleFemale
Do you have additional patient information to enter? E.g. additional children.*

YesNo

4th Patient's Name:*

First NameLast Name
4th Patient's Address*

Same as Patient 1New address
4th Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4th Patient's Date of Birth:*

MonthDayYear
Date
4th Patient's SSN:*
4th Patient's Gender*

MaleFemale

Financially 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(s):*
Employer:*
Occupation:*
Spouse's Name (or N/A):*
Relationship to Patient(s):
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 #:*
Upload the front of your insurance card:

Cancelof
Upload the back of your insurance card:

Cancelof
Is there a secondary insurance?*

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

Emergency Information
Emergency Contact:*

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

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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 1 Name:*

First NameLast Name
Patient 2 Name

First NameLast Name
Patient 3 Name

First NameLast Name
Patient 4 Name

First NameLast Name
The above named patient(s) (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(s) (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

Financially Responsible Party Information

Insurance Information

Emergency Information

Dental History

Dental History

Dental History

Dental History

Medical History

Medical History

Medical History

Medical History

Authorize Change Treatment

PRIVACY CONSENT

PATIENT PHOTO/VIDEO RELEASE

FINANCIAL AGREEMENT