10-2024 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 #:*
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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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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HIPAA
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certification.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, obtain payment, and conduct normal health care operations. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

By signing this form, you consent to our use and disclosure of your protected healthcare information as outlined in this form. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
May we phone/text/email you regarding your appointment?*

YesNo
May we send e-statements in regards to your account?*

YesNo
May we leave a message on your answering machine or voicemail?*

YesNo
May we discuss your medical condition with any member of your family?*

YesNo
If YES, please name the members allowed:
I, (print name)* have received a copy of this office's Notice of Privacy Practices.
Signature (Parent's signature if minor):*

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Date:*

MonthDayYear
Date

NOTICE OF FILMING & PHOTOGRAPHY
Patient Name:*

First NameLast Name
When you enter Boerne Orthodontics & Pediatric Dentistry (BOPD) you are entering an area where photography, audio, and video recording may occur.

By entering the premises, you acknowledge that photography, audio recording, video recording may occur, and may be used in publication, exhibition, or reproduction for news, webcasts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by BOPD and its affiliates and representatives. Images, photos and/or videos may be used to promote BOPD in the future, and exhibit the capabilities of BOPD. You release BOPD, its officers and employees, and each and all persons involved from any liability connected with the taking, recording, digitizing, or publication and use of interviews, photographs, computer images, video and/or sound recordings. It will always be our intention to obtain specific consent from those present prior to any such activity.

By entering the Boerne Orthodontics & Pediatric Dentistry (BOPD) premises, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, webcasting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, webcasting, or other publication irrespective of whether a fee for admission or sponsorship is charged.

You also waive any right to inspect or approve any photo, video, or audio recording taken by BOPD or the person or entity designated to do so by BOPD. You have been fully informed of your consent, waiver of liability, and release before entering the premises.
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

HIPAA

NOTICE OF FILMING & PHOTOGRAPHY

FINANCIAL AGREEMENT