New Patient Form | Scituate smiles

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Scituate Smiles

Welcome to Scituate Smiles!

Thank you for your warm welcome into the Scituate community. We're thrilled to serve your dental needs for many years to come. In order to serve you better, we're constantly updating all our patient records in accordance with HIPAA. Please fill out the following information and have your driver's license and insurance card ready.

Pref Name

First Name

Last Name

Date of Birth

SSN Number

Select an Address

Home Phone Number

Cell Phone Numer

Would you like to receive text message for future appointment reminders?

Yes

Dental Insurance Company

Dental Insurance ID

Dental Insurance Card Image Front

Upload File

Dental Insurance Card Image Back

Upload File

Policy Holder's Name & Date of Birth

Do you have secondary insurance?

Yes

Second Dental Insurance Company

Second Dental Insurance ID

Policy Holder's Name & Date of Birth

Dental Insurance Card Image Front

Upload File

Dental Insurance Card Image Back

Upload File

Medical History

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 medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes

If yes

Have you ever been hospitalized or had a major operation?

Yes

If yes

Have you ever had a serious head or neck injury?

Yes

If yes

Are you taking any medications, pills, or drugs?

Yes

If yes

Do you take, or have you taken, Phen-Fen or Redux?

Yes

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes

If yes

Are you on a special diet?

Yes

If yes

Do you use tobacco?

Yes

If yes

Do you use controlled substances?

Yes

If yes

Women : Are you..

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Other?

Have you ever had any serious illness not listed above?

Yes

If yes

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

NOTICE OF CONSENT

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
Obtaining payment from third-party payers (e.g. my insurance company)
The day-to-day healthcare operations of your practice.

I have been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date l revoke this consent is not affected.

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for the delivery of proper dental care.
I authorize the release of any information concerning my (or my child's) healthcare, for the advice and treatment provided for purpose of evaluation and administering claims for insurance benefits.
I authorize the release of any information concerning my (or my child's) healthcare, for the advice and treatment to another dentist, or another healthcare professional and their staff.

FINANCIAL RESPONSIBILITY
I hereby authorize payment of insurance benefits directly to the dentist, otherwise payable to me.
I understand that my dentist and staff will estimate insurance benefits as closely as possible. I understand that I am responsible for payment of the account, and providing correct insurance information.
I understand that if insurance is not applicable when dental services are rendered, then full payment is due at the time of service.
Proof of Insurance is required on all initial appointments.
We will bill most insurances, but it is the patient’s responsibility to know their own coverage.

BROKEN APPOINTMENT POLICY

Reserved appointment time at any office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure to do so deprives our other patients of receiving needed dental care in a timely fashion.

We now require 24 HOURS NOTICE for any Cancelled, Rescheduled, or Broken appointments. Failure to comply will result in a $25 BROKEN APPOINTMENT FEE.

DO WE HAVE PERMISSION FOR THE FOLLOWING?

Leave a reminder regarding your appointment on your voice mail?

Yes

Speak to other members of your household regarding your appointment?

Yes

Discuss your dental treatment with any member of your household?

Yes

Leave a message at your place of employment?

Yes

If yes to any of the above, whom?

Relationship:

Signature of Patient, Parent or Guardian :

Date