Patient Information

Patient Information
Name*

First NameLast Name
Gender*
Is anyone in your family a current patient?*

YesNo
Social Security Number*
Birth Date*

MonthDayYear
Date
Phone (Home)*
Please enter a valid phone number.
Phone (Cell)
Please enter a valid phone number.
Phone (Work)
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Contact

Text MessageE-mailPhone Call
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Information
Whom may we thank for referring you to our practice?

PatientDental OfficeSchoolRelativeYellow PagesWorkFriendInternet
Name of person referring you to our practice:
Health Information
Date of Last Dental Visit

MonthDayYear
Date
Reason for today's visit
Have you ever had any of the following? Please check all that apply.*

AIDS/HIV+AnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersMitral Valve ProlapseNervous DisordersPacemakerPregnantRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseNone of the Above
Do you have any allergies?*

YesNo
Are you currently on any medications?*

YesNo
Have you been admitted to the hospital or needed emergency care during the past two years?*

YesNo
Is this child up to date on all current vaccinations?*

YesNo
Are you now under the care of a physician?*

YesNo
Do you have any health problems that need further clarification?*

YesNo
Financial Agreement
In consideration for services rendered by Groovy Smiles Pediatric Dentistry and practitioners employed by Groovy Smiles Pediatric Dentistry, I guarantee prompt payment of all such services not paid by insurance carriers or third parties within thirty (30) days. I understand that any amount not covered by my insurance carrier or other third-party payer is my personal responsibility, and I agree to make payments for any such amount. If Groovy Smiles Pediatric Dentistry does not receive such payment within thirty (30) days from the date such balance is due, the bill may be turned over to an attorney or a collection agency and, if so, I agree to pay all reasonable collection cost including attorney's fees and/or collection fees in addition to the payment owed. I give Groovy Smiles Pediatric Dentistry the right to examine my consumer credit report for financial information related to my responsibility to pay for medical services.

Should your account be sent to a collection agency you agree, in order for "Mid-South Adjustment" to service your account or to collect any amounts you may owe us, Mid-South Adjustment may call the telephone number associated with your account. This includes wireless telephone numbers, which could result in charges to you. Mid-South Adjustment may also communicate with you by sending you text messages or e-mails to your wireless number or e-mail address. Methods of contact may include using prerecorded/artificial voice and/or the use of an automated dialing device. These authorizations shall remain in effect until individually withdrawn by you in writing to Mid-South Adjustment and/or any others to which authorization has been extended. I have read this disclosure and agree that Groovy Smiles Pediatric Dentistry may contact me as described above.
I have read and acknowledge the Financial Agreement.
Insurance Information
Does the patient have dental insurance?*

YesNo
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends on reimbursement from the patients for the costs incurred in their care and 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.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that a reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. 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 suited be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

I have read the above conditions of treatment and payment and agree to their content.
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with the office late fee, as well as current office procedures as outlined in the above text. *

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Date*

MonthDayYear
Date
Relationship to Patient
Groovy Smiles HIPAA Consent Form
THIS NOTICE DESCRIBES TO WHOM MEDICAL INFORMATION ABOUT YOU MAY
BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides
privacy protections to your medical records. Our benefits office (or other third party
designated by our office) may sometimes need to disclose medical information or
payment information protected by HIPAA in relation to our group health plans to your family members or close friends involved in your health care. For example, your spouse may need to contact us if you are in the hospital to determine whether a particular procedure is covered under our group health plan or may need assistance filing a claim for medical services. Under HIPAA, unless you specifically object we are allowed to use our professional judgment in deciding whether to discuss you medical and payment information with you family members or close friends. However, we would like to provide you with the opportunity to tell us with whom we may discuss your medical or payment information under our group health plans.
Groovy Smiles may communicate with the following individuals for relating to my medical or payment information:*
Groovy Smiles may NOT communicate with the following person(s):
COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
Groovy Smiles Office Policy
Groovy Smiles Pediatric Dentistry Appointment Policy

Need to reschedule an appointment? Let us know in advance!

We value your time!
Our goal is to provide our patients with beautiful, healthy smiles—and then get them on their way!

We know you don't need added stress in your life. We want to reduce unnecessary chaos and get you in and out as efficiently as possible, so you can get back to your already busy schedule. But we need your help!

Need to cancel?

WE HAVE MADE SOME POLICY CHANGES TO THIS PORTION, PLEASE READ THROUGHLY.

We require 48 hours' notice ahead of time. If you cancel your child's appointment with less than 48 hours notice, you will be charged a fee of $25 per child before you are able to reschedule the appointment.

Otherwise, if you cancel more than twice with less than 48 hours' notice OR skip your appointment without any prior notice, we will not schedule your family back at Groovy Smiles unless it's an emergency.
Should be Empty:

Patient Information

Referral Information

Health Information

Financial Agreement

Insurance Information

Groovy Smiles HIPAA Consent Form

Groovy Smiles Office Policy