Cocoa Beach Dentistry New & Current Patient Medical History Form

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

I have received a copy of this office's Notice of Privacy Practices

Full Name*

Today's Date*

Please type your full name in the box below.*

Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.*

Check here for electronic signature

Electronic signature date*

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Purpose: This form is used to obtain authorization to release information regarding you covered under the Privacy Act to people other than yourself. I authorize the following persons(s) to have access to information covered under the Privacy Practice regarding myself.

Click the plus button to add more people.

Full Name

Relationship

Insurance Financial Authorization and Release:

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Please type your full name in the box below.*

Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.*

Check here for electronic signature

Electronic signature date*

Out of Network Insurance Authorization:

I understand that my dental insurance is not accepted at this office location. I agree to be responsible for payment in full of all services rendered on my behalf or my dependents.

Please type your full name in the box below.*

Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.*

Check here for electronic signature

Electronic signature date*

Notice of Financial Responsibility No Insurance:

I understand that I am responsible for payment in full of all services as they are rendered on my behalf or my dependents.

Please type your full name in the box below.*

Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.*

Check here for electronic signature

Electronic signature date*

Cocoa Beach Dentistry New & Current Patient Medical History Form

New & Current Patients: Please fill out our Patient Medical History online form.
Please E-Sign the form when asked before submitting.
Thank you!

American Dental Association

New Patient Form

If you are filling out this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems?

DENTAL INFORMATION

MEDICAL INFORMATION Cont...

WOMEN ONLY

MEDICAL INFORMATION

Allergies

MEDICAL INFORMATION

Please check below to indicate if you have or have not had any of the following diseases or problems.

MEDICAL INFORMATION

Please check below to indicate if you have or have not had any of the following diseases or problems.

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health Issues prior to treatment.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Insurance Financial Authorization and Release:

Out of Network Insurance Authorization:

Notice of Financial Responsibility No Insurance:

New & Current Patients: Please fill out our Patient Medical History online form.Please E-Sign the form when asked before submitting.Thank you!

American Dental Association

New Patient Form

If you are filling out this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems?

DENTAL INFORMATION

MEDICAL INFORMATION Cont...

WOMEN ONLY

MEDICAL INFORMATION

Allergies

MEDICAL INFORMATION

Please check below to indicate if you have or have not had any of the following diseases or problems.

MEDICAL INFORMATION

Please check below to indicate if you have or have not had any of the following diseases or problems.

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health Issues prior to treatment.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Insurance Financial Authorization and Release:

Out of Network Insurance Authorization:

Notice of Financial Responsibility No Insurance:

New & Current Patients: Please fill out our Patient Medical History online form.
Please E-Sign the form when asked before submitting.
Thank you!