NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM
PATIENT INFORMATION
Today's Date

MonthDayYear
Date
Name

First NameLast Name
D.O.B

MonthDayYear
Date
SSN#
XXX-XX-XXXX
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email
example@example.com
Business Email
example@example.com
MinorSingleMarriedDivorcedWidowedSeparated
Patient's Employer
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Name

First NameLast Name
Spouse's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Employer
Whom May We Thank for Referring You?
RESPONSIBLE PARTY
Name of Financially Responsible Person

First NameLast Name
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
SSN#
XXX-XX-XXXX
YesNo
DENTAL INSURANCE INFORMATION
Name of Insured

First NameLast Name
Birthdate

MonthDayYear
Date
Relationship to Patient
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
SSN#
XXX-XX-XXXX
Name of Employer
Union or Local #
Group #
Policy/ID #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
AUTHORIZATON:
I authorize payment of insurance benefits directly to Valley Dental Group. I understand that I am responsible for any costs not covered by insurance. I authorize the dentist to perform necessary diagnostic and treatment procedures and confirm that the information provided on this form is accurate to the best of my knowledge. I also authorize the release of relevant dental and medical information to insurance providers and other healthcare professionals as needed for treatment and payment purposes.
Patient Signature (Parent or Guardian)

APPOINTMENT CANCELATION POLICY
We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an APPOINTMENT CANCELLATION POLICY that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient.

OUR POLICY IS AS FOLLOWS:

We require that you give our office 48 hours notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment time. If you miss an appointment without contacting our office within the required time, this is considerd a missed appointment. A fee of $75.00 will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibilty . No future appointments can be scheduled nor can records be transferred without the payment of this fee.

Additionally, if a patient is more than 20 minutes late, without prior notice, for a scheduled appointment, we will consider this a missed appointment and the $75.00 cancellation fee will be charged.

If you have any questions regarding this policy, please let our staff knowand we will glady clarify any questions you have.

We thank you for your patronage.

I have read and understand the APPOINTMENT CANCELLATION POLICY of Valley Dental Group and agree to be bound by it’s terms. I also understand and agree that such terms may be amended from time-to-time by the practice.
Patient Signature

PATIENT PHOTOGRAPHY AUTHORIZATION FORM
Today's Date

MonthDayYear
Date
Patient Name

First NameLast Name
Patient DOB:

MonthDayYear
Date
At Valley Dental Group, photographs are frequently taken as part of dental care to help document treatment, communicate with dental laboratories and support patient education. In some cases, these images may also be used to demonstrate treatment results and share educational information about dentistry. With your permission, photographs or recordings of your teeth, smile, or dental treatment may be used for:

• Educational presentations and professional lectures

• Teaching materials or publications

• The practice website or social media

• Informational or marketing materials for Valley Dental Group

Images will typically focus on your teeth and smile. Your name or personal identifying information will never be included without additional written permission. Your participation is completely voluntary, and choosing not to grant permission will not affect your care or treatment in any way. You may revoke this authorization at any time by submitting a written request, except where images have already been used or published. By signing below, you grant permission for Dr. Kevin Lassiter and Valley Dental Group to use photographs or recordings of your dental treatment for the purposes described above.
Educational Use Only (lectures, presentations, professional education)Educational + Practice Marketing (website, social media, printed materials)
Signature

FINANCIAL RESPONSIBILITY + INSURANCE ACKNOWLEDGEMENT
As a courtesy, Valley Dental Group will submit dental insurance claims on your behalf. However, your dental insurance policy is a contract between you and your insurance provider. While we strive to provide accurate benefit estimates, coverage, limitations, and payment decisions are determined solely by your insurance company.

By signing below, you acknowledge and agree to the following:
- I understand that it is my responsibility to know and understand the details of my dental insurance coverage.
- I authorize Valley Dental Group to submit insurance claims on my behalf.
- I understand that estimated insurance benefits are not a guarantee of payment.
- I agree that I am financially responsible for all charges related to my dental care, including any amounts not paid by my insurance provider for any reason.
- I acknowledge that I have read and understand the above information and accept financial responsibility for my dental treatment.
Patient Name

First NameLast Name
Today's Date

MonthDayYear
Date
Patient Signature (Parent or Guardian)

CONSENT FOR USE OR DISCLOSURE OF INFORMATION FOR PURPOSES REQUESTED BY VALLEY DENTAL GROUP
I hereby permit Valley Dental Group to use my health information, and/or to disclose my health information to any third party payor, or to any party involved in my health care.

I understand that there is a Notice of Privacy Practice posted in the office availble for me to read.

This consent shall be in force and effect as long as I am a patient in this practice.

I understand that I have the right to revoke this consent, in writing, at any time by sending such written notification to my doctor at this practice.

I understand that information used or disclosed pursuant to this consent may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

I also understand that I have the right to inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights.)
Patient Name

First NameLast Name
Patient Signature or Personal Representative
Description of Personal Representative Authority
Should be Empty:

NEW PATIENT INTAKE FORM

PATIENT INFORMATION

RESPONSIBLE PARTY

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

APPOINTMENT CANCELATION POLICY

PATIENT PHOTOGRAPHY AUTHORIZATION FORM

FINANCIAL RESPONSIBILITY + INSURANCE ACKNOWLEDGEMENT

CONSENT FOR USE OR DISCLOSURE OF INFORMATION FOR PURPOSES REQUESTED BY VALLEY DENTAL GROUP