Spring Hill: New Patient Form

Welcome to Smile Design!
Patient Information (Confidential)
Date:*
MM slash DD slash YYYY
How did you hear about our office?
Patient Name:*
First Last
Preferred Name:
Birth Date:
MM slash DD slash YYYY
Social Security #:*
Gender*
- M
- F
Marital Status
- Minor
- Single
- Married
- Divorced
- Other
Other
Guarantor/Resp. Party (Minors):
Guarantor/Resp. Party SS#
Birth Date:
MM slash DD slash YYYY
Home Address*
Street City State ZIP Code
Home*
Cell
Work/Other
Email Address*

Your e-mail address is used for appointment reminders, monthly promotions, follow ups, and newsletters. If at any time you wish to OPT out of any or all of these services, please contact the office.
Emergency Contact:
Phone:

Insurance Information
Subscriber Name*
First Last
Birth Date:
MM slash DD slash YYYY
ID/SS#:
Group #:
Insurance Company Name:
Phone #:
Employer:
Phone:
Address
Street City State ZIP Code

Patient Medical History
Are you under medical treatment now?
- Yes
- No
If yes, please explain:
Primary Care Physician:
Phone:
Specialty Care Physician:
Phone:
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
- Yes
- No
If yes, please explain:
Condition Year
Are you taking any medication(s) including non-prescription medicine?
- Yes
- No
If yes, what medication(s) are you taking?
Do you need to pre-medicate with antibiotics?
- Yes
- No
Do you use tobacco?
- Yes
- No
Do you use controlled substances?
- Yes
- No
Are you allergic to or have you had any reactions to the following?
- Barbiturates
- Local Anesthetics (eg. Novacaine)
- Latex Rubber
- Iodine
- Penicillin or any other antibiotics
- Sulfa Drugs
- Sedatives
- Any Metals (e.g. nickel, mercury, etc.)
- Aspirin
- Other (please list)
Other (please list)
Women Only: a) Are you pregnant or think you may be pregnant?
- Yes
- No
b) Are you nursing?
- Yes
- No
c) Are you taking oral contraceptives?
- Yes
- No
Do you have or have you had any of the following?
- High Blood Pressure
- Stroke
- Liver Disease
- Heart Attack
- Easily Winded
- Hepatitis/Jaundice
- Mitral Valve Prolapse
- Heart Trouble
- Leukemia
- Heart Murmur
- Frequently tired
- Cancer
- Low Blood Pressure
- Angina
- Radiation Therapy
- Heart Disease
- Chest Pains
- Recent Weight Loss
- Cardiac Pacemaker
- Thyroid Problem
- Fainting/Seizures
- Rheumatic Fever
- Kidney Disease
- Epilepsy/Convulsions
- Arthritis
- Diabetes
- Tuberculosis
- Anemia
- Asthma
- Respiratory Problems
- Glaucoma
- Emphysema
- Hay Fever/Allergies
- Swollen Ankles
- Aids/HIV Infection
- Sexually Transmitted Diseases
- Other
- Joint Replacement/Implant
- Stomach Troubles/Ulcers
Other (please list)
Do you have a Living Will?
- Yes
- No
If no, who will you appoint as your proxy in the event that you are unable to make your own medical decisions?
Contact #:
Relationship:

Release of Information Consent Form
I
*
have read and understood the HIPAA Notice of Privacy Practices that was provided to me by Smile Design Dentistry. However, In the event that I may need them to do so, I grant permission for Smile Design Dentistry and or staff to: (Please Check one of the following):
*
- 1- Discuss any aspect of my treatment and or needs with my: Spouse, Parent (if patient is over 18), Other
- 2- Have the above designated person, pick up any dental appliances, x-rays or dental records on my behalf.
- 3- I do not wish to have my information discussed with anyone outside of the parameters of Health Insurance Portability and Accountability Act of 1996.
Spouse
Parent (if patient is over 18)
Other Name
Relationship*

Relationship
Patient - Signature*
Date*
MM slash DD slash YYYY

Smile Design Dentistry
Cosmetic and Family Practice
Our Policy of Care and Payment

Ensuring that our patients receive high quality care is the goal of our practice! We strive to see every patient on time, however emergencies can delay the schedule occasionally. We thank you for your understanding.

Payment Options
- Cash or Check
- Debits Cards (with Visa/MasterCard logo)
- Major Credit Cards (MasterCard, Visa, Amex, Discover)
- HSA/Flex Spending Debit Cards (with Visa/MasterCard logo)
- Care Credit (interest free financing available)
- Citi Bank Health Card
- Lending Club
- Simple Pay
Applying for Care Credit and similar Payment Plans only takes a few minutes, and there is NO fee to apply.

Broken Appointments

Please call the office 48 hours (business days) in advance if you need to change or cancel your appointment with our office. We understand that there extenuating circumstances at times but this will allow us to better serve other patients needing to get an appointment and is greatly appreciated. A $50.00 set up and sterilization or broken appointment fee may be assessed if the appointment is broken without notice.

Insurance Agreement

This agreement is made between the undersigned patient below and Smile Design Dentistry. This form must be read and signed by the patient or the responsible party before the practice can accept payments directly from your insurance carrier.
- Patient/responsible party understands and agrees that he/she is responsible for all treatment fees on the patient’s account regardless of insurance estimates.
- Patient/responsible party understands and agrees that if for any reason your insurance carrier fails to pay the estimated portion that you are responsible for all balances on the account.
- Balances over 90 days are subject to be placed in collection’s that will include a 33% admin fee.
We accept and file insurance as a courtesy to our patients and insurance estimates are not a guarantee of payment by your insurance carrier. All insurance policies are not the same and it is the patient/responsible party’s responsibility to understand their policy.
Patient/Responsible Party Signature*

Patient/Responsible Party Signature
Date*
MM slash DD slash YYYY

Date

Smile Design Dentistry
Cosmetic and Family Practice
Patient Consent for Use of Credit Cards, Debit Card, and Financing
Disclosure of Protected Health Information

It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies, when requested, to facilitate your payment.

Services that are performed that are paid with a credit card, debit card, or financing third-party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Smile Design Dentistry to use and disclose my protected health information to any Credit Card Entity, Bank or Financing Company when they request such information to process an account and assist with payment.
I will not challenge such credit, debit, or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise.
I agree that this non credit card challenge agreement is irrevocable.
Signature of Patient or Legal Guardian*

Signature of Patient or Legal Guardian
Date*
MM slash DD slash YYYY

Date

SECURING FORM

Spring Hill: New Patient Form

Step 1 of 7

Welcome to Smile Design!

Patient Information (Confidential)

Insurance Information

Patient Medical History

Patient Dental History

Release of Information Consent Form

Smile Design Dentistry

Our Policy of Care and Payment

Payment Options

Broken Appointments

Insurance Agreement

Smile Design Dentistry

Patient Consent for Use of Credit Cards, Debit Card, and Financing
Disclosure of Protected Health Information

Condition	Year

Spring Hill: New Patient Form

Step 1 of 7

Welcome to Smile Design!

Patient Information (Confidential)

Insurance Information

Patient Medical History

Patient Dental History

Release of Information Consent Form

Smile Design Dentistry

Our Policy of Care and Payment

Payment Options

Broken Appointments

Insurance Agreement

Smile Design Dentistry

Patient Consent for Use of Credit Cards, Debit Card, and Financing Disclosure of Protected Health Information

Patient Consent for Use of Credit Cards, Debit Card, and Financing
Disclosure of Protected Health Information