www.drweigand.com - New Patient Form

New Patient Form
Name

First NameMiddle NameLast Name
Please call me by this name (Preferred)
Date of Birth

MonthDayYear
Social Security Number
(Required by many insurance companies)
Gender
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Wireless Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Place of Employment
Email
example@example.com
Preferred contact method
Emergency Contact
Emergency Contact Name
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Pharmacy Name
Location
Physician Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last physical
(estimation ok)
Insurance Information

Primary Dental Insurance Policy
Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Subscriber Name
Date of Birth

MonthDayYear
Subscriber ID Number
Employer
Group Name
Do you have secondary dental insurance policy?
Insurance Information

Secondary Dental Insurance Policy
Insurance Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Subscriber Name
Date of Birth

MonthDayYear
Subscriber ID Number
Employer
Group Name
FINANCIAL POLICY
At Dr. Weigand & Associates, we are committed to providing excellent dental care and clear communication about your financial responsibility. Your signature below indicates that you understand and agree to these policies. We are happy to answer any questions about cost, billing, or our expectations of payment.
PAYMENT OPTIONS
Patients (or responsible parties) are financially responsible for all charges incurred, including balances not paid by insurance. Full payment is required at the time services are rendered unless other arrangements are made in advance. We do not offer in-office payment plans.

We offer multiple payment options that include cash, check, Visa, MasterCard, and third-party financing. These are discussed as a convenience to you. Returned checks are subject to a processing fee of $25.00. Please contact our Patient Care Coordinator with any questions or concerns about these options.
PAYMENT AND INSURANCE POLICY
Our treatment recommendations are based solely on your dental health needs — not on your insurance coverage. We are not responsible for coverage determinations or benefit limitations set by your insurer. You are responsible for payment regardless of your insurer’s actual payment.

Full payment of the patient’s responsible balance is required at the time of service. We gladly provide an estimate of this and your insurance benefits and submit claims on your behalf, but the estimate is not a guarantee of payment by the insurer.

If you do not have dental insurance, full payment from you is required at the time of service.
DEPOSITS AND PRE-SERVICE ESTIMATES
If your services require a series of visits, 50% of the estimated patient-responsible portion is due at the start of treatment. For extensive procedures, a pre-service deposit may be required. Our Patient Care Coordinator will review pre-service payment or deposit requirements and the related payment schedule with you. Payment must be made prior to receiving the scheduled services.
ACKNOWLEDGEMENT
I have read and understand the Financial Policy stated above. I agree to pay all charges incurred for services rendered and accept full responsibility for the balance not paid by my insurance plan. Balances not paid when due may be considered delinquent. Delinquent accounts may be referred to a licensed third-party collection agency in accordance with applicable law.
Patient / Guardian Signature
Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Appointment Cancellation and No-Show Policy
We are committed to providing excellent care to all our patients. Missed or late-cancelled appointments limit our ability to offer timely treatment to others. Please read and understand the following policy, which applies to all scheduled appointments at Dr. Weigand & Associates.
Notice Requirements
If you are unable to keep your appointment, you must notify our office at least 48 hours in advance.

Call OR Text: 509-747-5812

Failure to give at least 48 hours’ notice will result in a missed appointment fee as outlined below
Types of Appointments & Fees for Missed or Late Cancellations

Appointment Type	Fee (if less than 48 hours’ notice or noshow)
Hygiene or Office Visit (e.g., Exam)	$50.00
Doctor Visit	$100.00

Note: Missed appointment fees cannot be billed to insurance and will be the patient's responsibility.
- Patients who miss or late-cancel three (3) appointments may be dismissed from the practice
- Repeated last-minute rescheduling, even with notice, may also lead to dismissal.
We appreciate your understanding and cooperation in helping us maintain timely, effective care for all our patients.
Patient / Guardian Signature
Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
This acknowledgement confirms that I have been provided access to or received a copy of this dental office’s Notice of Privacy Practices in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Washington State law, and related regulations.

I understand that this Notice of Privacy Practices describes how my dental provider may use and disclose my health information to carry out treatment, payment, and healthcare operations, and for other purposes permitted or required by law. The notice also describes my rights to access and control my protected health information.
I acknowledge and understand the following:
- I have the right to review the Notice of Privacy Practices before signing this acknowledgement
- A copy of the notice is available upon request and posted in the office and/or on the practice’s website.
- The office reserves the right to update or change the notice, and I may request a current copy at any time.
- I may request restrictions on how my health information is used or disclosed, but the office is not required to agree to those restrictions.
- I may revoke this acknowledgement in writing, except to the extent that action has already been taken in reliance on it.
I authorize to receive and discuss my protected health information, including treatment plans, appointments, and financial information, with the staff and providers at this office. I also permit this individual to participate in and assist with decisions regarding my care.
Patient / Guardian Signature
Relationship to Patient
(if not self)
Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

NOTICE OF PRIVACY PRACTICES-For your records
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. For more information about our privacy practices, or to request a copy of our Notice, please contact us using the information listed on this website.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment:

We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment:

We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations:

We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization:

In addition to our use or disclosure of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends:

We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare; but only if you agree that we may do so.

Persons Involved in Care:

We may use or disclose health information to notify or assist in notification (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x‑rays, or other similar forms of health information.

Marketing Health-Related Services:

We will not use your health information for marketing communications without your written authorization.

Required by Law:

We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect:

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security:

We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials’ health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or to a law enforcement official having lawful custody of protected health information of an inmate or patient under certain circumstances.

Appointment Reminders:

We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Patient / Guardian Signature
Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

New Patient Form

Emergency Contact

Insurance Information

Insurance Information

FINANCIAL POLICY

PAYMENT OPTIONS

PAYMENT AND INSURANCE POLICY

DEPOSITS AND PRE-SERVICE ESTIMATES

ACKNOWLEDGEMENT

Appointment Cancellation and No-Show Policy

Notice Requirements

Types of Appointments & Fees for Missed or Late Cancellations

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES-For your records

USES AND DISCLOSURES OF HEALTH INFORMATION