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Click Here To Download Form 1 and Form 2

Registration Form

  • Responsible Party (If someone other than tha patient

  • Patient Information:

  • Patient Information (Section 2):

  • Primary Insured Information:

  • Secondary Insurance Information:

  • Medical History

  • Although dental primarily treat the area in around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions:
  • NOTE: If Yes please Check Box and if No please leave it
  • To the best of my knowledge, the questions on this form been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. it is my responsibility to inform the dental office of any changes in medical status.

  • Financial & Cancellation Policy

  • We require payment in full for services rendered at the time of visit. We accept Cash, Check, Visa, Discover, American Express, Master Card, and CareCredit.
  • As a courtesy, we will file all primary insurance for you. It is your responsibility to present our office with your most current and up to date insurance card and the information necessary to file the claim. Failure to do so may cause you to be responsible for the entire account balance.
  • Payment of services applicable deductibles and co-payments are due at the time of your visit. We will estimate the portion to be covered by your insurance and your financial obligation for each dental procedure. This is only an estimate until the claim in paid by your insurance. You are responsible for all amounts not covered by your insurance company.
  • Prestonbrook Dental or a Corporation on our behalf will inform you of any outstanding balances after we receive payment from your insurance with a statement and our office does expect payment within 30 days or we reserve the right to ask an outside collection agency to collect these fees that are your responsibility.
  • Please notify our front office staff of any appointment cancellations or rescheduled appointments at least 24 hours in advance. Please be aware that there is a $35 service fee for all failed or cancelled appointments without a 24 hours notice.
  • The purpose for the charge is that the appointment time scheduled with the dentist was reserved for you. Out of consideration for another patient who may have needed that time, and in respect for dentist who designated the time for you, this charge may be imposed.
  • We sincerely appreciate you respecting our policy. I have read, understand, and agree to the above financial and cancellation policy.
  • We sincerely appreciate you respecting our policy.

    I have read, understand, and agree to the above financial and cancellation policy.



  • Signature: Patient or Responsible Party


    Date


    Printed Name


    Witness

  • Acknowledgement of receipt of Hipaa notice of privacy practices

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



  • Signature



  • Signature: Patient or Responsible Party


    Date


    Printed Name


    Witness
  • Please Note: it is your right to refuse to sign this Acknowledgement.