NEW PATIENT FORM - Phoenix Dentist

1 Welcome

2 Patient Information

3 Dental Insurance

4 Dental History

5 Notice of Privacy Practices

Dear New Patient,

Thank you for your interest in coming to our office as a new patient. My staff and I look forward to meeting you. We are confident that you will recognize and appreciate our extra-care approach to your dental needs.

Our primary concern is the preservation of your natural, healthy teeth. We also recognize that comfort, good appearance and long range economy are important as well; therefore, we practice in a preventative manner to restore optimum dental health and to maintain it that way.

Your dental appointment may take up to two hours . We welcome any questions you may have concerning your treatment, dental insurance or financial arrangements.

Please see the new patient forms. Please fill out the patient information and medical history form and sign in the appropriate places. If you have dental insurance, please fill out the insurance section to help expedite the processing of insurance claims.

We hope that your visit will be pleasant and comfortable as possible.

Please be advised, at least 48 hours’ notice is required to avoid a broken appointment fee.

Best Regards,

Marguerite P. Myers DDS

Dental Insurance
I have Dental Insurance*
- Yes
- No
Carriers*
- Primary
- Secondary
Primary Carrier
Policy Holder*
First Last
Birth Date*
ID / Social Security #*
Insurance Company*
Phone*
Group Policy #*
Employer*
Address*
Street Address City State ZIP Code
Secondary Carrier
Policy Holder*
First Last
Birth Date*
Social Security #*
Insurance Company*
Phone*
Group Policy #*
Employer*
Address*
Street Address City State ZIP Code
I authorize the release of treatment information to my insurance company for payment of benefits on my behalf. I also assign any insurance benefits to Marguerite P. Myers, D.D.S. unless I pay in full at the time of my treatment.
Date*
Signature*
By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.
Signature

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have received a copy of Dr. Peggy Myers Office's "Notice of Privacy Practices" This notice describes how Dr. Peggy Myers Office may use and disclose my health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information. This notice also informs the patient that Dr. Peggy Myers Office will not release any personal information for marketing purposes, or to related organizations. This notice takes effect April 14, 2003, and will remain in effect until we replace it.
Name
First Last
Date*
Signature*
By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.
Signature

Patient Information