Welcome Registration Form

Welcome to Healthy Smiles

Welcome to our office. We are happy that you have chosen us for your dental needs, and we will do our best to make your experience a pleasant one.

General Patient Information

Family Status:
Are you a Full or Part-time Student?

Responsible Party Information

THis ONLY needs to be filled out if the patient is under 18 years.

The following is for:
Family Status:

Dental Insurance

Primary Dental Insurance

Patient's relationship to insured:
Insurance Authorization:

Secondary Dental Insurance

Patient's relationship to insured:
Insurance Authorization:

Dental Information

How would you rate the condition of your mouth?
I routinely see my dentist every:
Check all that apply:

Financial and Office Policy Agreement

As with most professional offices, full payment for services is expected at each visit.

We accept: Cash, Check, Credit Card (Visa, Mastercard, Discover, American Express)

Care Credit/Citi Health Card/Lending Club - offers a separate line of credit to cover your entire family's dental care needs.

  1. A credit line can be best established and approval usually takes less than 10 minutes.
  2. Care Credit has an interest free option.
  3. There is no annual or membership fee.
  4. Monthly payment as low as 3% of the outstanding balance.

We will be happy to work with you to plan the most appropriate arrangements for your budget. Financing your treatment will allow you to begin your treatment immediately and spread the cost over a period of time.

Regarding Insurance

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. Please realize, however, that:

  1. Your insurance is a contract between you, your employer, and the insurance company. We are not party to that contract.
  2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each company. This applies only to companies who pay a percentage (such as 50% or 80%) of the "UCR". UCR- is defined as usual, customary and reasonable by most companies. This statement does not apply to companies who reimburse based on an arbitrary "schedule" of fees, which bears no relationship to the current standard and cost of care in our area.
  3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services that they will not cover. We must emphasize that as medical and dental care providers, our relationship is with you, not your insurance company. WHILE FILING OF INSURANCE IS A COURTESY THAT WE EXTEND TO OUR PATIENTS, ALL CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE THE SERVICES ARE RENDERED.
  4. We may accept assignment of insurance benefits for your procedure if the anticipated charge exceeds $300.00. If we agree to accept assignment of benefits for your dental treatment, we will require your estimated co-payment at the time of the procedure and will await payment of the balance from the insurance company. If the insurance company fails to pay all or part of the anticipated benefit, or if payment has not been received within 45 days, you are responsible for the entire balance. We agree to wait assignment of benefits from insurance carriers as a courtesy to our patients. However, please understand that YOUR INSURANCE COMPANY POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY, AND YOU ARE ULTIMATELY RESPONSIBLE FOR THE ENTIRE FEE SHOULD THE CO. FAIL TO PAY

Minor Patients

The parent or guardian accompanying a minor is responsible for full payment, regardless of any child custody and/or medical payment responsibility by the other parent NO CHILD UNDER THE AGE OF 18 WILL BE TREATED WITHOUT A PARENT OR LEGAL GUARDIAN PRESENT.

Collection Policy

A service charge will be added to all deficiency balances over 45 days. You will also be liable for any reasonable attorney and/ or collection fees and all related costs necessary to remit the balance back to this office.

Assignment of Benefits

Appointment Cancellation Policy

If unable to keep appointment, kindly give 48 hour notice. This will give us time to schedule other patients who are in need of treatment. Any cancellation less than 48 hours, a charge of $50.00 per person will be added to your account. Payment must be made on or before new appointment. Thank you for your cooperation.

Delinquent Account

There will be a flat fee of $30 for processing & for collection cost.
NOTE: There will be a processing fee of $25 for a duplicate copy of x-ray.

HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,

I authorize this office to disclose or discuss my personal and/or dental information with the following person(s).

(Please enter name and relationship to patient)

Consent for Internet Communications

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental. practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

Relationship to Patient

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.