www.travisbelldds.com - Personal Information Form

PLEASE COMPLETE AND RETURN TO BUSINESS OFFICE
Personal Information
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number (Primary)*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number (Primary)
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number (Primary)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Social Security Number
Date of Birth

MonthDayYear
Birthplace
Employer
Occupation
Insurance
Insured Person’s
Date of Birth

MonthDayYear
Relationship to Patient
Social Security # (of card holder)
Insurance Company Name
Employer’s Name
Group #
Subscriber ID (if assigned)
Upload a copy of the insurance card.

Cancelof
Getting To Know You
How did you hear about our office?
Whom may we thank for referring you?
Is another member of your family or relative a patient in our practice?
When was your last dental visit?
When was the last time you had dental radiographs taken?
Name & phone number of last Dentist
Have you ever had orthodontic treatment(braces)?
Have you ever had any teeth removed?
Emergency contact
Emergency Contact Name*
Relationship to Patient*
Emergency contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Payment
We accept Mastercard, Visa, Discover, American Express, Care Credit, Personal Checks, or Cash.

If you have dental insurance, we want to help you receive your full benefits and will be happy to assist you with this. Our patients are responsible for the account if you insurance company, for any reason, does not honor their commitment to you or us.

For long term or extended payments, we accept Care Credit.
FOR ALL PATIENTS
I hereby authorize the doctor to perform any/all forms of treatment, medication, and therapy that may be indicated in connection with the dental care of the patient above and further authorize and consent that the doctor chooses and employs such assistance as he/she deems fit. I also understand that previous to treatment, full explanation of the procedure(s) involved will be given by the doctor and/or team. I agree to pay for all services rendered by this office.
Signature of Responsible Party*

Clear
Relationship
Name*

First NameLast Name
Date*

MonthDayYear
Date

Authorization to Release Information
Patient Name*

First NameLast Name
Travis A Bell DDS PLLC is authorized to release protected health information about the above-named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient’s instructions. Please check each person / entity that you approve to receive information, then check the corresponding information that can be released.
Insurance, results of radiographs “X-rays”Appointment Times/RemindersOther (Explain)
Spouse (Provide Full Legal Name)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
InsuranceDental / MedicalFinancial
Parent (Provide Full Legal Name)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Give Information to Employer or School (Provide name)
Appointment Absentee Information
Other (Provide name & Relationship)
InsuranceDental / MedicalFinancial
EMAIL COMMUNICATION WARNING
Some communications with this office are transmitted by email with the entities below:
- Patient (Example: Appointment reminders, breach notifications, etc.)
- Insurance Companies
- Other dental and medical offices (Example: Prior records, referral information,etc.)
In order for email communication to occur, please accept the following disclosure below:
- I understand that if the information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to move forward to allow email communication.
PATIENT RIGHTS
- I have the right to revoke this authorization at any time.
- I may inspect or copy the protected health information to be disclosed as described in this document.
- Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
- Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
- I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
The information is released at the patient’s request and this authorization will remain in effect until revoked by the patient.
Signature of Responsible Party*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Travis A Bell DDS PLLC 526 N Elam Ave Suite 201 Greensboro, NC 27403 www.travisbelldds.com
Email: drtravisbell@gmail.com Phone 336-274-8386 Fax 336-274-8375

Acknowledgment of Receipt of Notice of Privacy Practices
Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I have received a copy of the Notice of Privacy Practices for the above-named practice.
Signature of Responsible Party*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Travis A Bell DDS PLLC 526 N Elam Ave Suite 201 Greensboro, NC 27403 www.travisbelldds.com
Email: drtravisbell@gmail.com Phone 336-274-8386 Fax 336-274-8375

Dental Records Release Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Other Family Members Transferring records
Previous Dentist or Practice Name
Previous Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous Practice Email
Required to obtain any previous radiographs "X-rays"
Please forward the following information obtained within the past 10 years: Radiographs “X-Rays”, Probing depth records, charting records, and photographs to the following practice:
Travis A Bell DDS PLLC
526 North Elam Ave Suite 201
Greensboro, NC 27403
drtravisbell@gmail.com
I hereby grant permission to release any and all of my dental record to Travis A Bell DDS PLLC
Patient Signature (Parent if a minor)*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Digital records may be email to:
drtravisbell@gmail.com

Physical records may be mailed to:
Travis A Bell DDS PLLC

526 North Elam Ave Suite 201
Greensboro, NC 27403
Travis A Bell DDS PLLC 526 N Elam Ave Suite 201 Greensboro, NC 27403 www.travisbelldds.com
Email: drtravisbell@gmail.com Phone 336-274-8386 Fax 336-274-8375
Should be Empty:

PLEASE COMPLETE AND RETURN TO BUSINESS OFFICE

Personal Information

Insurance

Getting To Know You

Emergency contact

Payment

FOR ALL PATIENTS

MEDICAL HISTORY

Women Only

Authorization to Release Information

EMAIL COMMUNICATION WARNING

PATIENT RIGHTS

Acknowledgment of Receipt of Notice of Privacy Practices

Dental Records Release Form