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ABOUT YOU

INSURANCE

Primary Insurance

Secondary Insurance

Emergency Contact

MEDICAL HISTORY

DENTAL HISTORY

I understand that the information that I have given today is correct to the best of my knowledge.  I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.  I have received a copy of this office's Notice of Privacy Practices.

Payment is due in full at the time of treatment unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibiles that my insurance does not cover.  I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me.  I understand that I am responsible for all costs of dental treatment.  I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

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HIPAA NOTICE OF PRIVACY PRACTICES
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Hours of Operation

Monday - Thursday

7am - 4pm

Saturday

By Appointment Only

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