New Patient Form

New Patient Form

We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please contact us - we will be happy to help.
New Patient Information

*Required Fields
Who may we thank for referring you?
About You

Please fill all the details Required
Name

First NameLast Name
I prefer to be called
Birth Date

MonthDayYear
Date
Age
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Employer
Occupation
Comment
Dental Insurance Information

Primary Insurance
Insurance Company Name
Group/Policy#
ID/Certificate or Employee#
Insured's Employer
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance
Insurance Company Name
Group/Policy#
ID/Certificate or Employee#
Insured's Employer
Insured's Name
Insured's Birthdate

MonthDayYear
Date
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
IN CASE OF EMERGENCY, WE SHOULD NOTIFY
Name
Relationship
Day-time Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Name of Medical Family Doctor
Phone or Address
Please enter a valid phone number.Format: (000) 000-0000.

APPOINTMENT POLICY
When you make an appointment with our office,we consider this a mutual commitment and reserve appropriate facilities and staff exclusively for you.In our office policy states that patient must give us 1 business day or 24 hours notice if they cannot keep an appointment.Late notice or missed appointment may be subjected to a minimum $60 charge
FINANCIAL POLICY
Payment in full is due the date of treatment, or on upon start of major treatment.We use Ontario Dental Association fee guide.

Payment Options
1. For your convenience we accept Cash, Debit, Visa, MasterCard.
2. We also offer short term financing options but interest charge will apply.All arrangements may be made in advance and subject to an approval process.

For Patients with Dental Insurance
Dental insurance plans often pay less than actual fee for service.Therefore the patient or Guarantor is responsible party for all the dental service provided.Dental insurance in most cases is a benefit with limitation should not be expected to take care of all costs. YOU ARE ULTIMATELY RESPONSIBLE FOR ALL COST INCURRED REGARDLESS OF WHAT YOUR DENTAL INSURANCE COVERS!
AUTHORIZATION AND CONSENT
General Consent to Treatment
I Agree and consent to a dental examination by Hardik Patel. I Understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.Also I acknowledge that there are no guarantees,expressed or implied, as to the result of any procedures or dental treatments performed.

Release of Information
I authorize Smiles by Dr. Patel to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.

Assignment of Insurance Benefits
I authorize and request my insurance company to pay my benefits directly to Hardik Patel.

I understand and comply with the office Appointment policy.
I understand and comply with the office Financial policy.
I understand and agree to the General consent to treatment.
I authorize the Release of Information.
I authorize the Assignment of Insurance of Benefits.
Signature
Date

MonthDayYear
Date
Should be Empty:

Rows	Drug	Purpose
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New Patient Form

New Patient Information

About You

Dental Insurance Information

IN CASE OF EMERGENCY, WE SHOULD NOTIFY

Medical History

Do you have or have you ever had

Are You

APPOINTMENT POLICY

FINANCIAL POLICY

AUTHORIZATION AND CONSENT