New Patients: Please fill out and submit all four forms below.

Thank you!

Form 1: New Patient Information

Form 1: New Patient Information

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Form 2: Medical History

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Form 3: HIPAA Notice

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, filing insurance, and health care operations.

You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and health care operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice at any time.

North Texas Dental Surgery

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

(“Acknowledgement”)


I acknowledge that I have received a copy of this Dental Practice’s HIPAA Notice of Privacy Practices.

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Form 4: Office Policies

CANCELLATION AND BROKEN APPOINTMENT POLICY

A reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure to do so deprives our other patients from receiving their dental care in a timely fashion.

Those who fail to keep their scheduled appointments should not penalize the Dentist, our staff, and mainly our other patients. Our dental policy stipulates that failure to give sufficient notice to keep a scheduled appointment will result in a fee being charged. That charge is in accordance with our dental office’s broken appointment policy for all of our patients. The patient is responsible for the payment of the charge.

  • Cancellation or rescheduling of an appointment with 48 hours notice or more notification: no charge
  • Cancellation, rescheduling, or failure to show-up for a scheduled appointment with less than 24 hour notice will be charged the following:

$75 for a doctor’s appointment

Every effort is made to contact patients to confirm. Our staff will contact you 2 days prior to your scheduled appointment to confirm with you. Please understand that this is a courtesy call, text, or email. DO NOT DEPEND ON THIS. If we are unable to reach you, your appointment card will serve as your confirmation of the appointment and implies your obligation to be present.

FINANCIAL POLICY

We accept cash, checks, money orders, Care Credit, and all major credit cards (Visa, MasterCard, American Express, and Discover).

Although we do accept the assignment of most insurance companies, your insurance is an agreement between you and your insurance company. We will do our best to see that you receive your full benefits.

Payment for dental service is expected and required at the time of service, unless other arrangements have been made. There is a $35 fee for any check returned for non-payment.

LATE PATIENT POLICY

Patients who arrive more than fifteen (15) minutes late to their scheduled appointment time may be asked to reschedule as a courtesy to our other scheduled patients.

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