New Patient Registration

Primary Dental Insurance Company

Employer

Ins. Co. Name

Insurance ID #

Address

Insured Party

Relation

Sex

Male Female

Date of Birth

Social Security #

Secondary Dental Insurance Company

Employer

Ins. Co. Name

Insurance ID #

Address

Insured Party

Relation

Sex

Male Female

Date of Birth

Social Security #

Have You Had Or Do You Currently Have...

Notes

Are you nursing, pregnant or trying to become pregnant?

Yes No

Do you take birth control pills?

Yes No

Fees & Payments

We make every effort to provide you with the finest surgical care and to keep down its cost. We will work with you to maximize your insurance reimbursement for covered procedures and will furnish you an estimate of charge for any procedure or surgery prior to service. Payment for services is due at the time rendered unless other arrangements have been made. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company.

This signature on file is my authorization for the release of information necessary to process my claim, I also authorize payment to this doctor named of the benefits otherwise payable to me.

Signature

HIPAA RELEASE

All patient records are confidential. A copy of our office privacy policy is available to me upon request. If anyone may be calling on the patient’s behalf, please complete this section. If you do not wish to add anyone, please complete name & D.O.B and sign & date at the bottom of this section.

Patient Name:

Patient D.O.B:

give the individuals listed below permission to access all health information/records pertaining

Name

Relation to patient

Date

Initials

Name

Relation to patient

Date

Initials

Name

Relation to patient

Date

Initials

Signature

At Peninsula Oral and Facial Surgery we think it is important to be transparent with our patients about any industry funding that our doctors receive. You can rest assured that no financial contribution from any industry partner will ever alter your care or our treatment recommendations. Pursuant with the requirements put forth by the California Medical Board any of our patients can find information about any financial support received from industry partners by using the database below. If you have any further questions about this, please do not hesitate to ask your doctor during your consultation. “The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at openpaymentsdata.cms.gov.”

Signature

Date

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NEW PATIENT REGISTRATION

Demographic Information

Patient

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health History

Health History

Have You Had Or Do You Currently Have...

Notes

Fees & Payments

Fees & Payments

HIPAA RELEASE

Procedures

Procedures

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