New Patient Form

NEW PATIENT FORM

This form is for new patients only.

Patient Information

*Patient Name

Gender

Preferred Name

Marital Status

Birthdate

SSS#

Driver's License #

Address

Home Phone Number

Work Number

Ext

*Cellphone Number

*Email

Whom can we thank for referring you?

**KK Smiles sends appointment reminders via email/text messaging unless otherwise advised**

Employer

Name of Employer

Occupation

Company Address

In Case of Emergency

Name

Phone Number

Primary Insurance Information

Subscriber

Date of Birth

ID #

Employer

Group #

Patient's relationship to insured:

Dental Insurance Co

Phone #

Address

Responsible Party

If other than yourself, who is the Person Responsible for this account

Relationship to Patient

Date of Birth

SSS #

Address

Dental History

What has brought you to our office today?

Previous Dentist

Last Dental Visit

How often do you brush your teeth?

Floss?

Type of Toothpaste

Type of Mouthwash

Do you use Tobacco Products?

How often?

Do you suffer from: (check all that apply)

Have you ever had gum disease therapy or deep cleaning? When?

Do you like your smile? Why/Why Not?

Have your past experiences in a dental office been positive?

Health Information
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Physician's Name

Date of Last Visit

Have you had any serious illnesses or operations?

Has your doctor told you that you need antibiotics to premedicate for dental work?

Women

Are you pregnant?

Nursing?

Taking birth control?

Have you ever had any of the following?

Are you presently taking any medications? If yes, please list.

Are you allergic to or have had adverse reactions to any of the following?

Any other medical conditions not listed above?

Authorization and Release
I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that I am financially responsible for all charges whether or not paid by insurance. Refusal to pay any and all outstanding balances could result in collection proceedings after 90 days delinquent. I authorize the release of any information, including the diagnosis and records of treatment/examination rendered, to my insurance company and other healthcare providers as necessary.

Photograph Release
In our office, photographs may be taken of our patients for aid in determining proper diagnosis and to help visualize with the appropriate treatment options. I hereby authorize KK Smiles to take photographs of my face, jaws, and teeth. I understand that the photographs will be used in a record of my care and may be used for research, publications, or educational purposes.

Cancellation Policy
We request two-business day advance notice for any change or cancellation of your appointment. This allows us the time we reserve especially for you in our schedule to be filled by another patient who may have been waiting for this appointment time. We do, however, understand that illness and other emergencies occur and we do make exceptions for those rare instances. A fee may be charged to your account for not adhering to this policy. For an appointment scheduled with our hygienists, the fee is $75.00. Appointments scheduled with the doctor will be charged a fee of $100.00.

Our Policy of Care and Payment
Payment is due at the time of treatment. As a courtesy to our patients, we will file for the estimated portion of payment provided by your primary insurance company, our office does not file secondary insurance. Any co-payment amount or non-covered portion is due at the time of treatment. Dental insurance is a contract between the patient and the insurance carrier, not the dental office. The insured patient is ultimately responsible for all costs of dental treatment. We accept cash, checks, Visa, Mastercard, Discover, and American Express. We also offer flexible payment plans with CareCredit, which allows you to start treatment today and spread payments over time.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Person: Angelia
Telephone: 770-952-5200

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the
Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

Signature

Date

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name

Relationship to Patient

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.

Please Sign: I understand and agree to all of the above

Patient Signature

Date

Parent/Guardian Signature

Date

If you are unable to fill-up the forms above. You may download our forms below. Please bring completed forms on your next visit.
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  • Download the necessary form(s), print it out and fill in the required information.