ARFD NPF

Patient Informaton

Dr. Tina Nichols | Dr. Samaria Mascagni
Name *

First Name Middle Name Last Name
Gender *

Male Female Other
Is anyone in your family a current patient? *

Yes No
What's their name?
SSN# *
Driver License #
Birth Date: *
Phone (Home): *

- Area Code Phone Number
Phone (Cell):

- Area Code Phone Number
Phone (Work):

- Area Code Phone Number
E-mail *
Preferred Method of Contact:

Text Message E-Mail Phone Call

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Referral Information
Whom may we thank for referring you to our practice?

Patient Relative Friend Dental Office Yellow Pages Internet School Work
Name of person or office referring you to our practice:
Health Information
Date of Last Dental Visit

- Month - Day Year
Reason for today's visit
Have you ever had any of the following? Please check those that apply *

AIDS/HIV+ Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Mirtral Valve Prolapse Nervous Disorders Pacemaker Pregnant Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Tuberculosis Tumors Ulcers Venereal Disease None of these
Do you have any allergies?

Yes No
Please list your allergies here:
Are you currently on any medications? *

Yes No
Please list your current mediations:
Have you ever had any complications following dental treatment? *

Yes No
If yes, please describe your dental complications.
Have you been admitted to the hospital or needed emergency care during the past two years? *

Yes No
If yes, please descibe your hospital stay.
Are you now under the care of a physician? *

Yes No
Is yes, please describe your current care.
Name of physician:
Phone Number:
Do you have any health problems that need further clarification? *

Yes No
Please explain.
Are you interested in any of the following:

Invisalign Orthodontics Implants Crown Partial Dentures Teeth Whitening
Are you happy with your smile? *

Yes No
Please tell us what about your smile you would like to approve upon
Employment Information
Employer Name
Occupation

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
Insurance Information
Does the patient have dental insurance? *

Yes No
Would you be interested in financing options?

Yes No
Name of Insurance Company
Name of Insured

First Name Middle Name Last Name
Insured's Date of Birth

- Month - Day Year
ID #
Group #
If you are on a smartphone or tablet and can take a photo of your insurance card, please do so now. If not please ignore this box.

Insured's Employer Name
Patient's Relationship to insured:

Self Spouse Child
Parent or Guardian Information
Please Select

Father Step-Father Guardian
Name

First Name Last Name
Home Phone

- Area Code Phone Number
Work Phone

- Area Code Phone Number
Cell Phone

- Area Code Phone Number
SSN#
DL#
Insured's Employer Name
Patient's relationship to insured

Self Spouse Child
Please Select

Mother Step-Mother Guardian
Name

First Name Last Name
Home Phone

- Area Code Phone Number
Work Phone

- Area Code Phone Number
Cell Phone

- Area Code Phone Number
SSN#
DL#
Insured's Employer Name
Patient's relationship to insured

Self Spouse Child
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. *
Date *

- Month - Day Year
Relationship to Patient
Arkansas Family Dental HIPAA Consent Form

Tina H Nichols, D.D.S. | Samaria Mascagni, D.D.S.
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out the following:
- Treatment (including direct or indirect by other healthcare provides involved in my treatment)
- Obtaining payment from third party payers (e.g. my insurance company)
- The day-today healthcare operations of your practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of the notice from time to time and that I may contact you at any time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and discussed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at anytime. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

Arkansas Family Dental Office Policies

Office Financial Policy

Payment is due the day of service. As a service to our patients we will file your dental insurance for you. As long as your insurance can be verified, you will only be responsible for your estimated percentage of treatment on that day of service. We can only give and estimate of what insurance will pay, any remaining balance is your responsibility.

48 Hours Notice Policy

It is very important that we receive notice of a change in plans at least 48 hours in advance. This gives us the chance to schedule another patient in your place. If we do not have sufficient notice regarding a schedule change, we will be unable to care for another patient in need of our services.

Arkansas Family Dental is sure that you understand why we must have policies along these lines. It is our policy to charge a $30.00 missed appointment fee to any patient that cancels their appointment the day of the appointment.

I understand that by signing this agreement I am expected to adhere to the policies set forth within this notice.
Name *

First Name Middle Name Last Name
Date *

- Month - Day Year
Relationship to patient
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 Arkansas Family Dentals HIPAA Consent form and all information held therein. *
Should be Empty:

Patient Informaton

Referral Information

Health Information

Employment Information

Insurance Information

Parent or Guardian Information

Arkansas Family Dental HIPAA Consent Form