New Patient Registration

(The following confidential information is for our records only)

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.


About You

Mr. Mrs. Ms. Dr.
Male Female
Single Married Divorced Separated Widowed

Spouse Information

Person Responsible For Account

Dental Insurance

Primary Dental Insurance

Secondary Dental Insurance

In the event of an emergency, is there someone who lives near you that we should contact?


Medical History

Although dental personnel primarily treat the area in and 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.

 

Do you have, or have you had, any of the following?

 


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

A 1.5% service charge will be added to all past due balances. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.


Payment is due in full at the time of treatment unless prior arrangements have been approved. Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CBC and the ADA.

FINANCIAL Guidelines

Thank you for choosing our office as your dental health care provider. At Campustown Dental we are committed to providing you with the best possible dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policy.

Payment is due at the time service is provided. Our quoted prices are discounted prices for payment by cash or check. Payment by credit card (Mastercard, Visa, American Express and Discover) does not receive our cash discount and is slightly higher. We also accept CareCredit and Wells Fargo Healthcare Financing. Outside financing is available upon request and approval. You are our main priority and we will gladly assist you by submitting all insurance claims pertaining to charges for care rendered in our office. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however that:

Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.

When our office calls to verify estimated insurance benefits the insurance company will always have a disclaimer that there is no guarantee of benefits. Insurance companies have the liberty to change your benefit structure at any given time without notifying our office. Having dental insurance does not guarantee payment.

We must emphasize that as a dental care provider, our relationship is with our patient and their families and not with their respective insurance companies. While the filing of the insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help you!

We ask that you sign this form required by your insurance company. This form instructs your insurance company to make payment directly to our office.

I acknowledge I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits to my dental office.

Campustown Dental complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-515-292-7262.

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-515-292-7262。


HIPAA Compliance Patient Consent Form

Campustown Dental’s notice of privacy practices provides information about how we use or disclose protected health information.

The notice contains a patient’s right section describing your rights under the law. you ascertain that by signature you have reviewed our notice of privacy practices.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare options. We are not required to agree with the restriction, but if we do, we shall honor this agreement. The HIPAA law allows for the use of the information for treatment, payment, or healthcare options.

By signing this form, I understand that:

  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
  • The patient has the right to revoke the consent in writing at any time and all full disclosures will then cease.
  • The practice may condition receipt of treatment on execution of this consent.

If you would like us to discuss your treatment with any member of your family please list below:

I attest that the above information is correct.

Campustown Dental complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-515-292-7262.

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-515-292-7262。


Campustown Dental Group

On a scale of 1 - 10, with 10 the highest rating:

How important is your dental health to you?
Where would you rate your current dental health?

If you could change your smile, you would:

 

 

Please check any of the following that apply :