Gentle Dentistry

Adult New Patient Form

Dentist In Kalamazoo, MI

  • General Information

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  • Responsible Party Information

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  • Insurance Information

    Primary Insurance

  • Secondary Insurance

  • Health History Questionnaire

    All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

    Dental History

  • Health History

  • If female, please answer the following

  • Allergies to medications

  • List all medications, supplements, and/or vitamins taken within the last two years.

  • I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the information provided.

  • Date Format: MM slash DD slash YYYY
  • Social Media & Website Consent Form

    First of all, thank you! Thank you for selecting Gentle Dentistry. We would love to post your review, picture, and experience here online at www.gentledentistrykzoo.com, within our website. If you would like to take part in recognizing our office online within our patient section, homepage, or testimonial on our website, Facebook, or Twitter, please sign below. This form states that you freely give consent to take part in our website, and authorize that your first name and only initial of your last name can be publicly displayed within Gentle Dentistry's website. You understand that by signing this form you are agreeing to take part in our online media source(s) and website. You have received a copy of this form to take with you, as well. We, the staff here at Gentle Dentistry, thank you. We were happy to have you as a patient here for all your dental health care needs.

  • Witness Statement

    I confirm that I was present for the verbal and written statement summary presented to the patient mentioned above, as well as the execution of this form. I agree that the information was accurately explained to, and apparently understood by, and that informed consent was freely given by the patient.

  • Written Financial Policy

    Thank you for choosing Gentle Dentistry. Our primary mission is to enable our patients to achieve excellence in oral health and freedom from head and neck pain. We will make every effort to provide quality dentistry in a caring and professional atmosphere.

    Payment Options

    Full payment is expected at the time of service. You may choose from:

    • Cash, check, credit card (Visa, MasterCard, and Discover), debit card
    • Payment Plans from CareCredit
  • Insurance

    We may accept assignment of insurance benefits providing all paperwork and necessary information is complete. We do require that deductibles and co-payments be paid at the time of service. Your insurance policy is a contract between you, your employer, and the insurance company. You, the patient, have the ultimate financial responsibility for treatment. If any services are rejected by your insurance, you are responsible for the fees. If we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits from your insurance carrier. Accounts not paid within terms are subject to a monthly statement fee.

    All levels of payment by insurance companies, including allowed fees, usual and customary (UCR), are governed by the premiums paid. The apyments have nothing to do with the actual charges. The treatment recommended by our office is never based on what your insurance company will pay but what your dental health needs are. Your treatment should not be governed by your insurance contract.

    Please take the time to review your insurance contract thoroughly so we may best serve you and help you to receive the maximum benefits toward your dental health. As always, you may feel free to ask any member of our team for clarification on services, billing, and insurance.

  • Cancellation Policy

    We would greatly appreciate a 48-hour notice from any patient (or patient representative) should they need to reschedule or cancel an appointment. We reserve the right to apply a cancellation fee if this policy is not respected.

    If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you need or want.

    I have read this policy and agree to it.

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  • HIPPA OMNIBUS RULE

    PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

  • You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.

  • Date Format: MM slash DD slash YYYY
  • The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

  • MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

  • PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

    (This includes step-parents, grandparents and any caretakers who can have access to the this patient's records):

  • In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you with this information with your knowledge and consent.

  • Office Use Only

    As Privacy Officer, I attempted to obtain the patient's (or representative's) signature on this Acknowledgement but did not because:

  • This field is for validation purposes and should be left unchanged.

Emergency Dental Care

Our dental office treats many types of traumatic dental injuries, such as teeth that have been chipped, moved, or knocked out. Please contact our Kalamazoo, MI office for help with a dental emergency.

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