Ward Family Dental - New Patient Paperwork

New Patient Paperwork

Ward Family Dental
Today's Date

MonthDayYear
Date
Patient Name*

First NameMILast Name
Preferred Name
Title
Mr/Ms/Mrs/etc
Gender*

MaleFemale
Family Status*

MarriedSingleChildOther
Birth Date*

MonthDayYear
Date
SS#
Prev Visit
Email Address
example@example.com
Best time to call
Home Phone*
Please enter a valid phone number.
Mobile Phone
Work Phone
Ext
Fax
Other
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Drivers License #*
Whom may we thank for referring you to our practice?
In an emergency who should be notified? Please enter Name and Phone number below:

Dental Insurance Information
Name of Insured*

First NameMILast Name
Insured's Birth Date*

MonthDayYear
Date
ID #*
Group #
Insured's Address

Street Address

Street Address Line 2

CityState

Zip Code
Insured's Employer Name*
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Patient's relationship to insured:

SelfSpouseChildOther
Insurance Plan Name*
Insurance Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company Phone Number
Policy Holder SSN#*
Have you ever had any teeth removed?

YesNo
How long have these teeth been missing?
Insurance Authorization

By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
If you have Secondary Dental Insurance, please present your insurance card to the front desk at the time of your appointment.
Signature

Clear
Date

MonthDayYear
Date

Have you taken or are you taking any Bisphosphonate drug used to treat osteoporosis, bone cancer or Paget's disease such as Fosomax, Actonel, Boniva, Reclast, Didronel, Zometa. Other related drugs such as Prolia, Forteo, Evista:

YesNo
Indicate drug type, drug name, dosage, and period of time taken (from when to when):
Do you have any allergies to medications, latex, metals, adhesives?*

YesNo
Allergies - please specify allergy, reaction(s), and severity:
Medical Doctor's name
Phone #
Preferred pharmacy
Pharmacy phone number (if located out-of-town)
Acknowledgement*

By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature (or that of the guardian).
Signature*

Clear

Consent for Services and Financial Policy
As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made. Arrangements MUST BE MADE in advance.

We do offer a savings for prepayment of treatment plans and an in-office savings plan for those without insurance. Please note that we are NOT Network, Preferred, or Participating Providers for any network. This is by our choice because we believe informed decisions should be made by the patient and not the insurance company. We will file and accept benefit payments and make every effort to help you maximize your insurance. You must realize, however, that:

1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
2. You and not your insurance company are ultimately responsible for payment, even if we have elected to accept assignment of benefits in your case.
3. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

A service charge of 1 1/2% per month will be charged on all returned checks and accounts exceeding 30 days, unless previously written financial arrangements are satisfied. Charges may also be made for broken appointments and appointments cancelled without 48 hour advance notice. Those charges can range from $75 to $400. Any account that is delinquent is subject to collection agency action. No account will be allowed to maintain a delinquent status.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant permission to you or your assignee, to telephone me to discuss this statement or my treatment.
*By checking this box, I understand the above information and agree with its contents, and this will serve as my electonic signature (or that of the guardian) for the Administrative Form.
Signature

Clear
Date

MonthDayYear
Date
Imaging and Recording Consent
Photos are taken of all our patients and are part of your private record. I give permission for photographs or video of me, or my child to be used for teaching, consultation, demonstration or publication purposes in print or electronic media.

If published, these will be presented without my identification (anonymously) and without showing my face.
Name or Name of Child*
I am aware that conversations with the doctor or staff may be recorded for training purposes. Face photos will only be published with my specific approval and with first name only.
Name of Person filling out this questionnaire if not Patient
Relationship to Patient*
By checking this box, I acknowledge that I have read this statement and agree to the contents. Checking this box will also serve as my electronic signature (or that of the guardian).
Signature

Clear
Date

MonthDayYear
Date

Office Policies
Our office policies are designed with you, the patient, in mind. They should answer any questions you may have regarding how our office treats scheduled appointments, cancelled appointments, late appointments, dental emergencies, and weekend emergencies.

Appointments

We are dedicated to staying on schedule and seeing all of our patients on time for their appointments. We do ask that our patients be on time for scheduled appointments, planning extra time for travel or filling out forms. We recommend arriving 5-10 minutes early to ease the check in process. Please be aware that dental emergencies do arise throughout the day which may delay or extend your appointment. We are committed to treating all true dental emergencies and will advise you immediately as to the status of your appointment.

Late Policy

We expect our patients to arrive on time for their scheduled appointment. Please note that we will have to reschedule your appointment if you arrive more than 10 minutes late. If you are habitually late, your appointment will need to be rescheduled, and you will be charged a fee of at least $50.00 for the appointment you forfeited.

Cancellations

We reserve the time especially for you. If you need to change your appointment, we ask for a minimum notice of 48 hours. According to our office policies, please be advised that you can be charged for a missed appointment fee from $70.00-$300.00. The fee is depending on the length of the appointment missed. Consecutive missed appointments can result in being dismissed as a patient.

Emergencies

If you have an urgent problem, please call our office immediately so we may see you as soon as possible. If you have an emergency after hours, please call our office for information on how to contact the doctor on call. If your after-hours emergency is unrelated to any recent dental care, you will be charged an additional fee for the after-hours care.

Thank you for your cooperation in helping us.
* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature (or that of the guardian) for the Office Policies Form.
Please sign

Clear

Agreement to Receive Electronic Communications of PHI
I agree that the dental practice may communicate with me electronically at the email address below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am responsible for providing the dental practice with any updates to my email address.
Email Address
example@example.com
Consent for Internet Communications
I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OF OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED, OR RECEIVED USING THE SITE OR THE SERVICES.

I can withdraw my consent to electronic/internet communications by calling 432-267-1677 (practice's telephone number).
I have read the information above regarding the secured uploading of patient information to the secure web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site. This will serve as my electronic signature.I decline to grant the dental practice permission to upload my patient information to the secure web site.
Name of person filling out this form:
Relationship to patient

SelfParentStep-parentGrandparentLegal GuardianOther
Please sign

Clear
This information is reserved to our practice. We do not sell or distribute information to anyone without patient's consent.

This material for general reference purposes only and does not constitute legal advice. It covers HIPAA only, no other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act and the U.S. Department of Health and Human Services rules and regulations.
Response Date

MonthDayYear
Date
Should be Empty:

	Yes	No
Are you able to chew well?
Do you have TMJ pain?
Do you have frequent headaches?
Are you very nervous about dental treatment?

New Patient Paperwork

Responsible Party Information

Dental Insurance Information

Medical History

Dental History Information

Consent for Services and Financial Policy

Imaging and Recording Consent

Office Policies

Appointments

Late Policy

Cancellations

Emergencies

HIPAA Acknowledgement

Agreement to Receive Electronic Communications of PHI

Consent for Internet Communications