implantsdentist.com - New Patient Form

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WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
ACCOUNT INFORMATION
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initialsI hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company, without exception.IN THE EVENT OF AN EMERGENCY
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	Name	Phone #
INTERNIS
CARDIOLOGIST
OTHER
PREVIOUS DENTIST

ROBERT J. MILLER, MA, DDS, DABOI, FACD

Our policy requires payment in full for all services rendered at the time of your visit unless other arrangements have been made in advance. If balance is not paid within 60 days from agreement we reserve the right to charge billing and interest fees per the current legal standards.

I authorize the Doctor & staff to perform any necessary services needed during diagnosis and treatment and the release of any information required to process insurance claims.

I have been made aware that the office of Dr. Robert J. Miller does not accept insurance unless otherwise approved in writing, but will file my insurance claims as a courtesy. Should my insurance not pay any or only a partial portion for services received, I am aware I am 100% responsible for any and all treatment performed in the office of Dr. Robert J. Miller.

I understand the office of Dr. Miller requires minimum of 48 hour notice to cancel an appointment. Should I not follow this requirement I agree to pay a fee of $30.00 for a broken hygiene appointment and up to $300.00 per hour for Dr. Miller.

Please sign below to indicate you have read the above information and understand and accept such in its' entirety without exception and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

Should I default on any or all payments to Dr. Robert Miller d/b/a The Center for Advanced Aesthetic & Implant Dentistry, I have been made aware I will be responsible for, but not limited to any and all payments for legal fees, legal filings, disruption of services for the doctor and staff, etc.
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Agreement to Receive Electronic Communication
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I initial DO AGREE.
I initial DO NOT AGREE.

That the dental practice may communicate with me electronically at the email address and/or mobile phone number listed below.

I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I further agree that I am responsible for providing the dental practice any updates to my email address and/or mobile phone number.
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WELCOME TO THE PRACTICE

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MEDICAL HISTORY

Agreement to Receive Electronic Communication