New Patient Form

New Patient Form
Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Birthdate

MonthDayYear
Date
Age
Occupation:
Employer:
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone
Please enter a valid phone number.
Person responsible for this account
Is another member of your family a patient at our office?
Whom may we thank for referring you?
Person to contact for an emergency?
Emergency Contact Phone Number
Please enter a valid phone number.
Text MessageEmailBoth
Your Spouse

(for insurance reasons)
Spouse Name

First NameLast Name
Occupation
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Business Cell
Please enter a valid phone number.
Insurance Information
Primary Carrier:
Insurance Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
I.D. #
Group #
Relationship to Insured
Insured SSN
Insured Birthday

MonthDayYear
Date
Your SSN if different
Secondary Carrier:
Insurance Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
I.D. #
Group #
Relationship to Insured
Insured SSN
List all medications, prescription and non-prescription, that you are currently taking:
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- Name
- Dosage
- Reason
- SIGNA TURE OF PA TIENT, PARENT, OR GUARDIAN
  
  Clear
- Date
  
  MonthDayYear
  Date

To Our Valued Patients,

We would like to welcome you to our office. Please take a few moments to read the following with regard to our payment policy.

If you have no dental insurance, payment in full is required at the time of service.

If you have PPO dental insurance, we will be happy to bill your insurance company for you. Your estimated patient portion of the fee will be due at the time of service.

We are not currently contracted with any insurance plans or dental groups. We are happy to assist you in billing for any PPO dental plan only.

Please understand that we cannot always discern from your insurance card the exact plan in which you are enrolled or the exact benefits that you are eligible for. You will need to be familiar with your dental coverage specifics. We always welcome questions and are available to help you understand your insurance if we can. If you need to make financial arrangements, please speak with us prior to your appointment time.

We request a 48 hours notice if you need to cancel or reschedule your dental appointments. Bro-ken appointment fees with less than 48 business hours notice (not including Fridays) or “no show” appointments will be charged the rate of $150 per hour reserved.
Initials Signature Only
I have read and understand the above material and agree to its standards. I have received the Notices of Privacy Practices.

Clear
I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my dental needs/my child’s dental needs.

Clear
I authorize release of any information concerning my health care, advice and treat-ment provided for the purpose of evaluation and administration claims for insurance benefits. I, the undersigned, grant permission to Restore Dental Studio, Dr. Justine Castor, DDS and Kathleen Carson, DDS to utilize my x-rays and/or photos for advertisement, social media & educational purposes as needed

Clear
Patient Name

First NameLast Name
Signature of Patient, Parent or Guardian

Clear
Name of Patient, Parent or Guardian

First NameLast Name
Should be Empty:

New Patient Form

Personal Information

Your Spouse

Insurance Information

Primary Carrier:

Secondary Carrier:

List all medications, prescription and non-prescription, that you are currently taking:

Medical History

Women: Are you

Do you have, or have you ever had any of the following:

Treatment Recommendations or Treatment Options?

Dental History

Initials Signature Only