HEFFELFINGER - Registration

Registration

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Today's Date
Date Format: MM slash DD slash YYYY
Patient's Name*
First Last
Sex
- Male
- Female
Birth Date
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
SSN
Email
Marital Status
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Driver's License
Name of Insured
First Last
Insured's SSN
Insured's Employer
Insured's Birth date
Date Format: MM slash DD slash YYYY
Are you a full time student?
- Yes
- No
If patient is a minor, we need:
Mother's Birth date
Date Format: MM slash DD slash YYYY
Father's Birth date
Date Format: MM slash DD slash YYYY
EMERGENCY INFORMATION: Name, Address, Telephone # of a relative not living with you
How did you hear about our office?
Is email or text message confirmation of your appointments ok?
- Yes
- No
Primary Dental Insurance Information
Name of Insured
First Last
Insured's Birth date
Date Format: MM slash DD slash YYYY
Insured's SSN
Insured's Employer
Insurance Company
Group #
Local #
Secondary Dental Insurance Information
Name of Insured
First Last
Insured's Birth date
Date Format: MM slash DD slash YYYY
Insured's SSN
Insured's Employer
Insurance Company
Group #
Local #
FAILED APPOINTMENT: Your appointment time is reserved just for you, so that we can provide you with our fullest attention. We realize that at times you may need to reschedule your appointment due to unforeseen circumstances, if you need to cancel your appointment, kindly give us at least 24 hours notice so we can accommodate other patient* who ire waiting to receive treatment. In the event you do not show up for your appointment or do not cancel within 24 hours, your account will be charged a $50.00 fee far a failed appointment. In the event of future failed appointments, your account will be charged $50.00 for each occurrence. After three failed appointments, we reserve the right to dismiss you from our practice. LATE ARRIVAL: Late arrival for a schedule appointment leads to inadequate time to accommodate the remaining patients on the schedule. As such, late arrivals of greater than 10 minutes may not be seen due to lack of time available. In addition, those patients who are on the schedule and have arrived at their assigned time will be seen first. We will try to accommodate late arrivals, time permits.

CONSENT: I have READ, UNDERSTAND and AGREE to the above terms and conditions. I AUTHORIZE my insurance company to PAY my dental benefits DIRECTLY to my DENTAL OFFICE. I. the undersigned, hereby authorizes Smiles For Life LLC to take X-Rays, make study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Heffelfinger to make a thorough diagnosis of my or my dependents dental needs. I also authorize Dr. Heffelfinger to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk and that in rare instances permanent paresthesia may result. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made I further understand that a finance, rebilling, collection charge or attorney fee will be added to any overdue balance

Signature

Date

Comments

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Registration

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If patient is a minor, we need:

Primary Dental Insurance Information

Secondary Dental Insurance Information