New Patient

Personal Details

Title

First Name*

Last Name*

Preferred Name

Date of Birth (mm/dd/yyyy)*

SSN

Gender

Home Phone

Mobile Number*

Can we contact you via SMS/Text?

?? Yes No

Language

How did you hear about us?

Other reference name*

Add Address Details

Address

City

State

Zip

Add Emergency Details

Emergency Name

Emergency Phone

Do you have Insurance?

Yes

Upload insurance documents

Relationship to patient*

Insured Birth Date (mm/dd/yyyy)*

Subscriber ID*

Group Number

Insured Social Security Number

First Name of Insured*

Last Name of Insured*

Employer Name

Ins Company*

Other Ins Compay

Disclaimer

I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.

Relationship To the Patient*

Name if not the Patient*

Patient or Guardian Signature *

30 July 2021 at 10:17 PM by IP 3.235.120.150

Manassas Dental Smiles Financial Policy

Thank you for choosing our practice to serve your dental needs.

Please take the time to read the following, initial each section, and sign and date the bottom of this form.

Full payment is due at the time of service unless arrangements have been made prior to the start of any treatment.

Insurance balances are ultimately the patient’s obligation. We will file most primary insurances at no cost to you as a courtesy. However, insurance balances which are not paid within 60 days may be billed to you. Please keep your walk-out statements and follow up with your insurance carrier to ensure prompt payment.

Some of your treatment may not be covered by your insurance carrier. The cost for such charges will be your responsibility.

Major services may require a deposit equal to at least one half of the estimated patient portion at the time the appointment is made.

Patients are asked to confirm their appointments at least 48 hours in advance by directly contacting our office or by responding to our confirmation contact. Failure to confirm your appointment may result in a charge for the time reserved.

There will be a fee of $30.00 for any checks returned as Non-Sufficient Funds (NSF)

Patient balances that go unpaid for 30 days or more may incur one or more of the following charges:

Interest charges of 1.5% per month

30 July 2021 at 10:17 PM by IP 3.235.120.150

COVID-19PANDEMICNOTICEANDACKNOWLEDGEMENT OF RISK

The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a
protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

I have read and understand the information stated above:

Patient's Signature,

30 July 2021 at 10:17 PM by IP 3.235.120.150