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*

Subscriber ID*

Group Number

Name of Insured *

Insured Social Security Number

Insured Birth Date (mm/dd/yyyy)*

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 *

25 October 2020 at 02:48 PM by IP 34.232.51.240

Notice of Privacy Policies

Acknowledgement of Receipt of Notice of Privacy Practices

A copy of our Notice of Privacy Practices was made available and I, [FName] [LName], acknowledge receipt of that notice.

Electronic Data

Do we have your permission to transmit your information by conventional email to other offices for referrals or communication? There may be some level of risk that the information in these emails could be read by a third party. We currently use a HIPAA compliant encrypted email service.

I have had the full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permision.

Patient, Parent or Guardian's Signature

25 October 2020 at 02:48 PM by IP 34.232.51.240

OFFICE FINANCIAL POLITY

Due to a recent increase in the amount of last minute cancelled or "no show" appointments, we are implementing the following new policies. We understand that unanticipated events happen occasionally in everyone's life, the late train or last minute meetings etc. But in our desire to be effective and fair to all our patients, the following policies are in effect at AGAPE DENTAL STUDIO.

Scheduled Appointments- When a patient schedules an appointment they are responsible for that date and time. Our office provides many ways to remind patients of their appointments as a COURTESY. We send text or email reminders and also call patients. Patients are ultimately responsible to confirm their scheduled appointments. If there is no confirmation your appointment may be given to someone else to avoid an unproductive schedule in our office.

24 Hours Advance Notice- If you are unable to make your CONFIRMED scheduled appointment we do ask you to give the office 24 hours’ notice. This allows the opportunity for someone else to schedule an appointment at this time. If the CONFIRMED appointment is not cancelled within 24 hours a $50.00 cancellation fee will be applied to your account.

No Shows- Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a NO SHOW and a $50.00 missed appointment fee will be applied to your account.

Late Arrivals- If you arrive late, your appointment may be shortened in order to accommodate others whose appointment follows yours. Depending upon how late you arrive, your Dr. will then determine if there is enough time remaining to start your treatment. Out of respect and consideration to your Dr. and staff and other patients, please plan accordingly and please be on time.

We value all of you as patients and look forward to seeing you at your next appointment here at AGAPE DENTAL STUDIO!

I affirm that the information I have given on this form is correct to the best of my knowledge and it is my responsibility to inform this office of any changes in my medical status. I authorize my insurance benefits to be paid directly to Agape Dental Studio and I understand that I am responsible for the payment of deductibles, co-payments, and any balances not covered by my insurance. I further understand that fees for professional services rendered are payable in full within 30 days. A service charge of 1% per month will be added to all account balances for 60 days old; this is an annual rate of 12%. I understand that if my account becomes delinquent, I may be referred to a third party for collection. If this should be turned over to collections, the processing fee 35%-50% will apply to the balance. I also understand that future dental services may be limited for all persons under my account until my account is current. I also authorize Agape Dental Studio to release any information required to process my claims. I understand that payment is due at the time of service.

I have read and agree to the terms in this OFFICE FINANCIAL POLICY.

25 October 2020 at 02:48 PM by IP 34.232.51.240

Medical Form

Notice of Privacy Policies

Acknowledgement of Receipt of Notice of Privacy Practices

Electronic Data