New Patient Paperwork

Patient's Full Name*	Preferred Name
Parent or Guardian's Name(s) if patient is a minor (18 & under)
Date of Birth*	Social Security Number*
Mailing Address* (Address, City, State, ZIP)
Personal Phone*	Work Phone
Email Address*	Best Phone # to Reach You Personal PhoneWork Phone
Marital Status* —Please choose an option—MarriedDivorcedWidowSingle	Employer
Who may we thank for referring you to our office?

Primary Dental Insurance

(Leave blank if there is no dental insurance to file)

Insurance Company Name
Name of Subscriber (Person who carries the insurance)
Subscriber's Date of Birth	Subscriber's Social Security Number
ID Number	Group Number
Subscriber's Employer

Secondary Dental Insurance

(Leave blank if there is no dental insurance to file)

Insurance Company Name
Name of Subscriber Person who carries the insurance
Subscriber's Date of Birth	Subscriber's Social Security Number
ID Number	Group Number
Subscriber's Employer

Broken Appointment & Cancellation Policy

We hold appointment times especially for you in good faith that you will be here. When patients do not show up or cancel at the last minute (regardless of the reason) we cannot fill the open slot. This results in nonproductive time which results in increased fees for everyone. We appreciate your understanding. There will be a $25-$50 charge for ALL missed appointments and cancellations with less than 24 business hours prior to the scheduled appointment time.

Policy for Filing Insurance

Our office is NOT in network with any dental insurance providers, however as a courtesy we will file to all dental insurance companies. You will be responsible for any charges your insurance does not pay. If for any reason your insurance company has not paid within 60 days of treatment the balance will be your responsibility and you will need to refile with your insurance company. The patient’s estimated portion will be due at the time of service.

Payment Services

If you are a self-pay patient with no dental coverage all financial responsibility must be paid at the time of service. In the event you do have insurance but are unable to provide us with the insurance card you may be asked to pay in full at the time of service. When insurance is provided we give an estimate to the best of our knowledge. In the event insurance does not pay in full you are responsible for the balance. All balances on accounts must be paid within 30 days. All delinquent accounts will be sent to the magistrate’s office or collection agency.

By signing below, I attest that the above information is correct to the best of my knowledge. I also understand that payment is due when services are rendered and that I will be responsible for any amount that insurance does not cover.