Patient Information
Patient Name *
Patient Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Birth Date *
Birth Date
This is used to verify insurance benefits.
Whom may thank for referring you?
Insurance Information
Insurance Company Phone Number
Insurance Company Phone Number
Policy Subscriber
Policy Subscriber
Phone Number
Phone Number
Birth Date
Birth Date
This is used to verify insurance benefits.
Dental History
Check if you have or have had problems with any of the following:
Medical History
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain.
If yes, please explain
Women: Are you...
Select all that apply.
Are you allergic to any of the following?
Select all that apply.
Check if you have or have had problems with any of the following:
HIPAA & Office Policies
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 1. Plan and direct my treatment and follow-up among multiple health care providers who may be involved in that treatment directly and/or indirectly. 2. Obtain payment from third party payers, including my insurance company. 3. Conduct normal health care operations, such as qualify assessments and physician certifications. I have received, read, and understand this Notice of Privacy Practices. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operation. I understand that treatment by the practice may be denied if I do not sign this consent.
Perimeter Dental Policies We encourage you to ask any questions you might have regarding our policies. Financial policy: 1. Patient estimates are provided as a courtesy and are not a guarantee of benefits. 2. Payment of your estimated patient portion (deductible, co-pay, or co-insurance) is expected at the time the service is begun, not completed. In cases where lab work is done, payment will be due prior to any lab cost being incurred by the practice. We will accept cash, personal checks, and the following credit cards: Visa, Master Card, Discover, American Express, and CareCredit. 3. The patient will be responsible for any dollar amount not covered by insurance after payment is rendered. Scheduling policy: 1. Appointments missed or cancelled within 24 hours of the scheduled appointment will result in a $50.00 fee. This $50.00 will need to be paid prior to rescheduling your appointment. 2. Same day cancellations will not be rescheduled same day, allowing you time to review your schedule. 3. We do our best to run on time and we ask that our patient’s respect our time, as we do theirs. Please arrive to your appointment on time so that we do not fall behind or have to rush on your treatment. We will provide a 10 minute courtesy call to see if you’re on your way. If a patient is 15 minutes late, we reserve the right to break your appointment and charge the appropriate fee. 4. 4. Perimeter Dental does reserve the right to dismiss a patient for frequent cancellations, tardiness, inappropriate behavior, or disrespect towards a doctor or our staff. If a patient is dismissed, we will require their balance be paid immediately.