Drs. Paul and Kathy Helsby2100 Aloma Ave., Suite 200

Winter Park, Fl. 32792

PATIENT REGISTRATION

First Name: __________________________ Last Name: _____________________________________________Middle Initial _______Preferred Name: _____________________________________ Patient is: ______Policy Holder _______Responsible PartyBirth Date: ____________________ Soc Sec: __________________________ Drivers License: ________________________________Address: ______________________________________________________ Address 2: _______________________________________City, State, Zip: _____________________________________________________Email: _______________________________________Home Phone: ________________________ Work Phone: ________________________ Ext ____ Cell___________________________Drivers License # ______________________________________________ Email: ___________________________________________ Employer: _____________________________________ Employer Address: _____________________________________________ Emergency Contact: ______________________________________ Emergency Contact #: ____________________________________Sex: ___Male ___ Female Marital Status: ____Married ____Single ____Divorced ____ Single ____Separated ___ WidowedWhom may we thank for referring you: _______________________________________________________________________________ Responsible Party (if someone other than the patient) _________________________________________________________________ Address: __________________________________________________ Address 2: _______________________________________ City, State, Zip: _____________________________________________________Email: ___________________________________ Home Phone: ________________________ Work Phone: ________________________ Ext ____ Cell_______________________ Drivers License # __________________________________________ Email: ___________________________________________

INSURANCE INFORMATION

______Patient is Policy Holder _____Responsible Party is Policy Holder for Patient

Name of Insured: ______________________________________________ Relationship to Insured: ___ Self ___Spouse ___Child ___OtherInsured Soc Sec: _____________________________________________ Insured Birth Date: ________________________________________Employer: ____________________________________________________ Insurance Company: _______________________________________ Address: __________________________________________________ Address: __________________________________________ Address 2: _________________________________________________ Address 2:_________________________________________

City, State, Zip : ____________________________________________ City, State, Zip: _____________________________________ Phone #:_____________________________________

Drs. Paul and Kathy Helsby2100 Aloma Ave., Suite 200

Winter Park, Fl. 32792

Dental Financial Policy and Agreement

Thank you for choosing us for your dental needs. We are committed to providing you with excellent care. Our convenient financial arrangements are based on an open and honest discussion of recommended treatment options.

PAYMENT Payment in full is due at the time of service unless prior financial arrangements are made. We offer several payment options:

Cash, Checks, Visa, MasterCard, Discover and American Express Care Credit for patients interested in making payments over a 6 month period

INSURANCEOur office is committed to helping our patients maximize their benefits. Because insurance policies vary greatly, we can estimate your coverage in good faith, but cannot guarantee it. As a service to our patients, we will be happy to manage all claim submission and follow up on your behalf. If there is a difference in dollar amount due, a statement will be sent to you and is due upon receipt.

MISSED/CANCELLED APPOINTMENTS

Once an appointment has been made, that time is reserved specifically for you- we do not double book. We reserve the right to charge a fee ($50) for all appointments cancelled or missed without a full 24 hours notice. Appointments made for Mondays need to be cancelled by 3pm on the previous Thursday.

SERVICE CHARGESThere is a billing fee and a monthly interest fee of 1% on all accounts 60 days past due.

COLLECTION FEESFees incurred to collect payment will be billed to and payable by the patient’s account holder.

FINANCIAL CONSENTThe patient (account holder) agrees to be fully responsible for total payment of treatment performed in this office.

RESPONSIBLE PARTYThe responsible party (the insurance policy holder) is responsible for the financial agreement listed above for all patients under said insurance policy

I understand and agree to this Financial Policy and Agreement

_______________________________ _________________________Signature of Patient/Responsible Party Date

___________________________________Print Name of Patient/Responsible Party

Drs. Paul and Kathy Helsby2100 Aloma Avenue

Suite 200Winter Park, FL 32792

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received a copy of the Notice of Privacy Practices. This notice describes how my health information may be used or disclosed. I understand that I should read it carefully. In addition, I am aware that the notice may be changed at anytime. I may obtain a revised copy of the notice by requesting one at this office.

__________________________ __________________________

Date Signature

__________________________

Printed or typed name

As the representative of the above individual, I acknowledge receipt of the notice on his/her behalf.

__________________________ __________________________

Signature Relationship

__________________________ __________________________

Printed or typed name Date