www.shinedentalteam.com - New Patient Form

Financial Policy
We appreciate that you have chosen Shine Dental Arts for your oral health care needs. We understand that every patient has unique financial situations, and we are here to help. To ensure clarity and comfort, here are the key points to our financial policy:
Payment Options: Payment is due at the time of service. We accept cash, checks, debit cards, and all major credit cards.*
Initial
Insurance: We will submit your insurance forms and help collect payments. Any amount not covered by insurance is the patient’s responsibility*
Initial
Financing: We offer Care Credit for patients seeking financing for their dental treatment. Please ask for more information if you are interested.*
Initial
Balances: We utilize Abella, a third-party service, to notify you of any outstanding balances. You will receive notifications via text or email regarding your balance. Additionally, we may reach out through text, phone call, or mail to remind you of unpaid balances. We kindly request that you settle any outstanding balances promptly. If you encounter any extenuating circumstances, please inform us so that we can collaborate on creating a suitable plan moving forward.*
Initial
Appointment Changes: We reserve time and prepare a room specifically for your dental needs. If you need to reschedule, please provide at least 48-hour notice. We do not charge for missed appointment, but we would greatly appreciate your commitment to the scheduled appointment times.*
Initial
Thank you for understanding and cooperating with our financial policies. We're here to answer any questions you might have and to make your experience as smooth and pleasant as possible.
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date

Patient Consent to Receive Mail, Text, and Telephone Messages
We utilize texting as a convenient and efficient method to communicate important information and reminders to our patients.
Do we have your permission to:
Send a recall appointment reminder to your phone/home?*

YesNo
Leave appointment, billing or dental information on your answering machine, voicemail, text, or email?*

YesNo
Consent to Share Information
Would you like to give permission to an individual for Shine Dental Arts to share your information with them?*

YesNo
Add Names (Click + for add more)*
Acknowledgement of Receipt of Notice of Privacy Practices - HIPAA
We have our Notice of Privacy Practices for any patient requesting a copy at the front desk.
Signature of Patient / Parent or Legal Guardian *

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Name*

First NameLast Name
Date*

MonthDayYear
Date
Additional Requests
If there are any additional recommendations, requests, or information that you feel we should know, please feel free to express yourself in the following lines:
Should be Empty:

	0	1	2	3
Sitting and Reading
Watching TV
Sitting inactive in a public place
Lying down to rest in the afternoon when circumstances permit
Sitting in a car as a passenger for a continuous hour
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
Sitting in a car stopped in traffic for a few minutes

New Patient Form

Personal Information

Insurance

Emergency Contact

Assignment and Release

Consent

Medical History

Conditions

Allergies

Patient Acknowledgment and Certification

Dental History

Airway Obstruction Screening

Financial Policy

Patient Consent to Receive Mail, Text, and Telephone Messages

Consent to Share Information

Acknowledgement of Receipt of Notice of Privacy Practices - HIPAA

Additional Requests