Patient Registration Form
(Patients will be asked to update patient registration information every 3 years)
(required for all patients 18 and over)
Primary Dental Insurance Information
(Patients will be asked to update patient registration information every 3 years)
Financial Agreement
Patient(s) with Dental Insurance
You are solely responsible for payment to Pro Dental for dental treatment rendered even if you are covered by dental, medical or accident insurance. As a service to you, Pro Dental will file your insurance claim with your insurance carrier. We ask that you provide our office with correct and/or updated insurance information at each appointment or whenever you have a change in coverage. I hereby authorize payment directly to Pro Dental of dental benefits otherwise payable to me.
Pro Dental is authorized to provide any insurance company (s), claim administrator (s), and consulting health care professionals, information concerning health care advice, the purpose of evaluating and administrating claims for benefits. This authorization is valid for the term of coverage of the policy or contract, enforce on this date only, or for one year, whichever is shorter. I know I have the right to receive a copy of this authorization upon request and agree that the photographic copy of this authorization is a valid as the original.
Patient and/or Authorized Person’s Signature *
Signature (Insured Person)
All Patients
In consideration for Pro Dental to provide you with dental treatment, you agree that all fees and co-payments are due and payable on the day that treatment is rendered to you unless other payment arrangements have been agreed to in writing by Pro Dental. Cash, Visa®, MasterCard®, Discover®, American Express®, and Care Credit® are all acceptable methods of payment. We do not accept payment by Check.
If your account balance is not paid in full within 30 days of treatment being rendered, you agree to be subject to interest charges of .66% per month (8%apr). In the event that your account becomes delinquent and is not brought current, you understand that in addition to your outstanding balance, you agree to be responsible for all collection costs (35% of balance due) and reasonable attorney fees incurred by Pro Dental or on behalf of Pro Dental. You understand that you are solely responsible for payments in full of all account you may have with our office.
Appointment Policy
Pro Dental requires a 24 hours notice to change or cancel an appointment. A first appointment that is broken, cancelled, failed or rescheduled less than 24 hours will not rescheduled. If an existing patient’s appointment is cancelled without 24 hours notice same day appointments will only be allowed. I understand I may be dismissed as a patient upon three of these occurrences.
I consent to Pro Dental using my cell phone number to (choose one or both)
regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time. My cell phone number is (include area code):
Pro Dental reserves the right to charge a fee of $75.00 for any failed appointments if we do not receive a notice of cancellation prior to the scheduled appointment time.
I understand that I can withdraw my consent at any time. My cell phone number is (include area code):
Pro Dental reserves the right to charge a fee of $75.00 for any failed appointments if we do not receive a notice of cancellation prior to the scheduled appointment time.
Patient and/or Authorized Person’s Signature *
Acknowledgement of Receipt Notice of Privacy Practices
Located on Clipboard (laminated pages) or we can print out upon request.
I, have reviewed a copy of this office’s Notice of Privacy Practices and consent to photos for patient file and/or of treatment.
Patient and/or Authorized Person’s Signature *
At Pro Dental we value our patients time and will make every effort to see patients in a timely manner in relation to their scheduled appointment. If it has been 10 minutes or more past your appointment time, please notify the Front Desk Staff and they will assist you. Additionally, if you have commitments immediately after your appointment, please make the Front Desk Staff aware so that we can assist you in maintaining your schedule.
I Authorize, to discuss the financial and/or dental records for myself/dependents/spouse named below with the staff at Pro Dental. By signing this, I do not hold the authorized person responsible for any information shared.
Patient or Authorized Signature *
Submit
