Sekhon Dental - New Patient Welcome Form

New Smile, New You!

Dentist for the Whole Family!
Welcome and thank you for choosing Sekhon Dental!

We're very grateful that you've chosen us for your dental care. Sekhon Dental Inc. is a boutique family dental practice serving the community since 1979. At Sekhon Dental, we are committed to providing the best dental care and experience by using the latest technology and techniques, providing a relaxing and professional environment. Our entire team is committed to answering your questions and making sure you have an extraordinary experience from the moment you walk in. We want all your treatment to be comfortable, long-lasting and to exceed your expectations. We always strive to provide unequaled value. This is what sets us apart!

Please take a moment to complete this welcome patient package to make your
transition as smooth as possible and to learn more about you. Please read each
document carefully so you can become familiar with our practice values and policies.

We are happy to answer any questions you may have at any time. Our team is looking forward to providing you with the best dental care. Again, welcome and thank you for choosing Sekhon Dental Inc. Please also visit us at sekhondental.com.

Keep Smiling,

Dr. Navjot Sekhon, DDS and Team

NOTE: Please complete all forms to the best of your ability!

Patient Information Sheet
Patient Full Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Minor or Have Guardian:

YesNo
Guardian (First and Last Name)

First NameLast Name
SS # *
ID #
Gender*

MaleFemale
Marital Status*
Occupation
Home Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Email Address*
name@email.com
Address *

Street Address

Street Address Line 2

CityState

Zip Code
Employer
Position
How Long?
Is Patient Responsible Financially?*

YesNo
Complete Only if Patient is NOT responsible
Responsible Party Name (First and Last Name)

First NameLast Name
Date of Birth

MonthDayYear
Date
SS #
Gender

MaleFemale
Relationship to Responsible Party
Cell Phone
Please enter a valid phone number.
Email Address
name@email.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Employer
Position

Dental Insurance

Primary
Do You Have Dental Insurance?

YesNo
Interested in FREE teeth cleanings, X-Rays and exams? Join our membership plan! Visit our website or ask us how we can save you money.
Subscriber Name (First and Last Name)

First NameLast Name
Relationship to Subscriber
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
SS #
Employer
Employer Phone
Please enter a valid phone number.
Insurance Company
Phone Number
Please enter a valid phone number.
Group #
Plan
Policy #
Effective Date

MonthDayYear
Date
Dental Insurance

Secondary
Do You Secondary Insurance?

YesNo
Subscriber Name (First and Last Name)

First NameLast Name
Relationship to Subscriber
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
SS #
Employer
Employer Phone
Please enter a valid phone number.
Insurance Company
Phone Number
Please enter a valid phone number.
Group #
Plan
Policy #
Effective Date

MonthDayYear
Date
FAMILY MEMBERS (who are patients in our practice)
EMERGENCY CONTACTS
How Did You Hear About Us?*
If Other or Referral Name
Upload Your Picture ID (Parent or Guardian's ID if a minor)*

Cancelof
Primary Insurance Card (Front)

Cancelof
Primary Insurance Card (Back)

Cancelof
Secondary Insurance Card (Front)

Cancelof
Secondary Insurance Card (Back)

Cancelof
We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial, scheduling and communication responsibilities with our practice.

Initials Required
I agree and understand that I must provide a 72-hour notice to avoid being charged $75 for last minute cancellations, no-shows or missed appointments.

I fully understand that payment is due at the time of service.

I agree to have my photograph stored in Sekhon Dental, Inc.’s electronic medical records system. I understand that by signing below, I am giving Sekhon Dental, Inc. permission to take and use my photograph in its electronic medical records system for identification purposes.

By signing below, I acknowledge that I have read, fully understand, and agree to be bound by these consents.
PATIENT SIGNATURE (Guardian, if a minor):*

Clear
Date:*

MonthDayYear
Date

Insurance Policy Statement
Whether you currently have dental insurance or not. This is to inform you about your insurance policy should you obtain dental insurance in the future.

Please read carefully our office policy regarding dental insurance.

You are fortunate to have dental insurance, whether you have purchased it or your employer has provided it for you. We will go the extra mile to help you maximize your insurance benefits. As a courtesy, we will help you filing your insurance forms, which will save you considerable time, money and trouble. We accept payments from most insurance companies, which reduces your immediate out-of-pocket expense.

Regardless of what we may calculate your insurance company to pay, it’s only an estimate. Our estimate is based on limited information obtained from you and your insurance company. We cannot forecast what they will pay.

Your dental insurance is not designed to pay the entire cost of your treatment, but it’s intended to help cover a certain portion of the cost. Better terms for dental insurance may be “dental assistance” or “dental benefits.” You will be responsible for the total treatment fee.

Please remember, however, that the financial obligation for dental treatment is between you and this office, not between this office and your insurance company.
Patient Signature*

Clear
Date:*

MonthDayYear
Date

Patient Acknowledgements
I hereby acknowledge that I have received a copy of
1. Sekhon Dental Inc.’s Notice of Privacy Practice
2. Dental Materials Fact Sheet
3. Insurance Policy Statement
Print Name*
Signature*

Clear
Date:*

MonthDayYear
Date
If this acknowledgment is signed by a personal representative on behalf of the patient, complete the following:
Relationship to Patient
Notice of Privacy Practices
Should be Empty: