New Client Registration Form

New Client Form

We are so glad to have you at Mint Dental. Save time on your first visit by filling out the information below. We can’t wait to meet you!

Name

First Name

Last Name

Preferred Name

Title (Mr. Mrs. Ms., etc.)

Gender

Family Status

Birth Date

YYYY

Social Security Number

Previous Visit

YYYY

Best time to call:

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Work Phone

(###)

###

####

Extension

Fax

(###)

###

####

Other

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Whom may we thank for referring you to Mint Dental?

Emergency Contact's name, phone number and relationship:

Employment Information

The following is for:

Employer Name

Employer's Number

(###)

###

####

Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Responsible Party Information

Are you the responsible party? If no, please complete this section:

The following is for:

Name

Last, first

Middle Initial

Preferred Name

Title (Mr. Mrs. Ms. etc.)

Gender

Family Status

Birth Date

YYYY

Social Security Number

Drivers License Number

Email Address

Best time to call:

Home

(###)

###

####

Mobile

(###)

###

####

Work

(###)

###

####

Extension

Fax

(###)

###

####

Other

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Dental Insurance

Name of insured (last, first)

Birth Date

YYYY

ID #

Group #

Insured's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insured's Employer Name

Employer Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's relationship to insured

Insurance Plan Name:

Insurance Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company Phone Number

(###)

###

####

Do you have a secondary dental insurance, if yes, please provide information to the reception staff

By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

I agree

Consent for Services & Financial Policy

As a condition of treatment by this office, financial responsibility on the part of each client must be determined before treatment. We except payment by cash, check, debit or credit cards, and Care Credit. All returned checks will be assessed a $35 returned check fee. The practice depends upon reimbursement from clients for the costs incurred in their care. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in full at the time services are performed unless other arrangements are made. Clients with dental insurance understand that all dental services are charged directly to the client that he or she is personally responsible for payment of all dental services. It is imperative that current and accurate insurance information be provided by the client at the time of their appointment. Insurance policies are a contract between the client and the insurance company. It is the client’s responsibility to know and understand their plans requirements regarding copayments, coinsurance, deductible, benefits, and coordination of benefits. Copayments are due at the time of service. We agree to use any insurance information provided to bill your insurance company and apply to your account. Clients who do not have insurance coverage are considered self-pay. Payment in full for services provided are due at the time of service. I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the client examination. I agreed to pay the charges for the services at the time of treatment or within five days of billing if credit is extended. I further agree that the charges for services shall be as build unless objected to, by me, in writing, within the time payment is due. I grant my permission to mint dental to contact me to discuss the statement or my treatment. We offer a 5% pay in full discount when paying in full with cash, checks, or debit cards with a pin. Credit cards are not eligible for the pay in full discount. We offer a 5% senior discount to clients who are 60 years of age or older. This discount may be combined with the pay in full discount when applicable. Parents or legal guardian of a minor client (under 18 years of age) who signs the minor’s paperwork is solely responsible for providing payment for services rendered. Any accounts with charges that remain unpaid for 90 days from the last date of service will be treated delinquent or “past due”. Past due accounts may subsequently be reviewed for assignment to collections. We reserve the right to decline to provide further services on clients if the account is delinquent or past due. The account may be opened again once the account is paid in full or if there has been an agreed, signed payment arrangement made.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.

HIPAA

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of oral health care operations. The Statement of Privacy Practices also describes my rights and responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. The office reserves the right to change the privacy practices that are described in the statement of privacy practices. If privacy practices change, I will be offered a copy of the revised statement of privacy practices at the time of my first visit after the revisions become effective. I may also obtain a revised statement of privacy practices by requesting that one be mailed to me. In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically grant permission of my protected healthcare information to include treatment, account information to the persons indicated below. (Please enter name and relationship on the lines below)

By checking this box, I understand the above information and agree with its contents and this will serve as my electronics signature for the HIPAA Disclosure Form

I agree

Authorization For Use Or Disclosure Of Patient's Photo's and/or Video Images

Authorization: I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the office. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations. Revocability: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the authorization for use or disclosure of patient photographic and/or video images.