Patient Information

Name*
Birthdate*
Address*

Health Information

Do you have or have you ever had any of the following? (Please check all that apply)

Have you ever had any complications following dental treatment?
Have you ever been hospitalized or had a major operation in the last two years?
Are you under a physician's care now?

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)

Referral Information

Responsible Party Information

The following is for:
Responsible Party Name
Birthdate
Address

Employment Information

The following is for:
Employer Address

Primary Dental Insurance Information

Insured's Name:
Is insured a patient?
Insured's Birthdate
Insured's Address
Insured's Employer Address
Patient's Relationship to insured:
Do You Have A Secondary Dental Insurance?

Secondary Dental Insurance Information

Insured's Name:
Is insured a patient?
Insured's Birthdate
Insured's Address
Insured's Employer Address
Patients Relationship to insured:'

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon 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.

A service charge of 1ó% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

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 the 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 a suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home, by cell or at my work to discuss matters related to this form.

I have read the above conditions of treatment and agree to their content.

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Date

Authorizations and Acknowledgments

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION


I understand that, under the Health Insurance and Portability & Accountability Act of 1996, I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare
Providers who may be involved in that treatment directly and indirectly.
Obtain payment from third party payers.
Conduct normal healthcare operations such as assessments and physician certifications.

I have received, read and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.

By placing my name and date below, I acknowledge that I have read and understand the above policies. Should I have any questions, I can contact the practice at any time.

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Name
Date

I authorize Wellspring Family Dental, PA to share my information with the people listed below.

 

The information we may share would possibly include information about: treatment and/or financial arrangements and payment for services. If you are 18 years old or older, but are insured on another family member’s insurance, you should list that person’s name below.

Spouse
Parents
Any member of the immediate family (parents, grandparents, siblings, others)
Others

Email & SMS Communication Release

PATIENT E‐MAIL AND TEXT MESSAGING


Due to the changing world of healthcare and technology, we now have the ability to provide our patients with certain types of information via e‐mail and/or text messaging.


We believe strongly in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from us via email or text messaging. We do not share the names, e‐mail addresses, and/or telephone numbers of patients with any other companies, or with any other patient.


By placing my name and date below, I acknowledge that I have read and understand the above statement on emails and text messages. Should I have any questions, I can contact the practice at any time. I hereby give permission to send messages to me via email and/or text messaging as means of communication.

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