09:09 AMTIME

PATIENT REGISTRATION

8/18/2015DATE

First Name:

ID:

Patient Is: Policy Holder Responsible Party

Last Name: Middle Initial:

Preferred Name:

Chart ID:

Responsible Party ( if someone other than the patient )

First Name: Last Name: Middle Initial:

Address: Address 2:

City, State, Zip: Pager:

HomePhone:

Work Phone: Ext: Cellular:

Birth Date: Soc Sec: Drivers Lic:

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Patient Information

Address: Address 2:

City: State / Zip: Pager:

HomePhone:

Work Phone: Ext: Cellular:

Sex: Male Female Marital Status: Married Single Divorced Separated Widowed

Birth Date: Age: Soc Sec: Drivers Lic:

E-mail: I would like to receive correspondences via e-mail.

Section 2 Section 3

EmploymentStatus:

Full Time Part Time Retired

Student Status: Full Time Part Time

Medicaid ID: Pref. Dentist:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg:

Referred By

Previous Dentist

Emergency Contact

Primary Insurance Information

Name of Insured: Relationship to Insured: Self Spouse Child Other

Insured Soc. Sec: Insured Birth Date:

Employer:

Address:

Address 2:

City, State, Zip:

Rem. Benefits: Rem. Deduct:

Ins. Company:

Address:

Address 2:

City, State, Zip:

Insured Birth Date:

Employer:

Other

Insured Soc. Sec:

Address:

Rem. Benefits: Rem. Deduct:

Address 2:

City, State, Zip:

Secondary Insurance Information

Name of Insured: Spouse ChildRelationship to Insured: Self

Ins. Company:

Address:

Address 2:

City, State, Zip:

Emergency Contact #

Financial Policy

Thank you for choosing Lakewood Ranch Family & Cosmetic Dentistry for

your dental care. We are committed to outstanding dental service

with each patient’s individual needs in mind. Please take time to read the following and initial each section. _____ Full payment or your estimated portion is due at the time of service. _____ We accept cash, checks, Visa/Mastercard, American Express and Discover. We can also provide information for low/no interest financing for qualified applicants. _____ Your insurance plan is a contract between you and your insurance company. We are not a party to that contract. We will file your insurance provided we have been given complete and accurate information. Please be aware that any balance is your responsibility, whether your insurance company pays or not for the treatment rendered. In the event, your insurance company does not pay your claim within 60 days, the balance does become your responsibility. _____ During the course of your treatment, it may be necessary to provide services that your insurance company does not cover. The payment for these services is your responsibility and further determinations of these services are strictly an issue between the insurance company and yourself. _____ Any account over 90 days that goes without payment will be turned over to a collection agency, which is HIPAA compliant and adheres to all current legislation, and responsible party/patient will be held responsible for any & all fees incurred by this transaction. Patient Signature ____________________ Date ____________

Contact Preferences  

How would you like to be contacted?  __ Phone Call                                          Preferred Phone Number:         _____________________  __ Text Message                                    Preferred Cell Phone Number:  _____________________  __ E‐Mail                                                 Preferred E‐Mail Address:   ______________________________ 

  

 Appointment Cancellation Policy 

 We understand that unplanned issues can come up and you may need to reschedule an appointment. If that happens, we respectfully ask for at least 24 hours advanced notice.  Our doctors and hygienists are reserving time especially for you. When a patient does not show up for a scheduled appointment, another patient loses an opportunity to be seen. Although we have always had a cancellation policy, circumstances have caused us to enforce a policy of charging for no‐show appointments, and those appointments not rescheduled with at least 24 hours advanced notice. As of July 1, 2014 there will be a fee of $50.00 per hour assessed if we do not receive a call to reschedule an appointment with 24 hours advanced notice.  Thank you for being a valued patient and for your understanding and cooperation as we institute this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of all patients.   The Staff of Lakewood Ranch Family & Cosmetic Dentistry   _________________________________________ Pt Signature                                                     Date