New Patient Information Form

1Contact Information

2Financial Information

3Dental Release Information

4Signature: Your rights and permissions

Minor Child - May need to complete both blocks for parent information

Adults - Complete primary insured

Duel Coverage? Also complete secondary insured

Dental Insurance 1st Coverage

Policyholder name

First Middle Last

Policyholder address

Street Address Address Line 2 City State ZIP Code

Policyholder phone number

Policyholder date of birth

Relationship to Patient

Employer

Name of insurance company/address

Social Security Number

Subscriber number

Policyholder GROUP ID number

Dental Insurance 2nd Coverage (if different then primary)

Policyholder name

First Middle Last

Policyholder address

Street Address Address Line 2 City State ZIP Code

Policyholder phone number

Policyholder date of birth

Employer name

Name of insurance company

Policyholder ID number

Policyholder GROUP ID number

Consent

Financial Agreement & Cancellation Policy

In order to assist you in making payments for your dental treatment, several options are available. Payments may be made by cash, check, credit card (VISA, MasterCard or Discover) or Care Credit. We reserve the right to charge a $25.00 fee for all checks returned for non-sufficient funds. Unless other arrangements have been made, your balance is due at the time services are rendered.
If you have dental insurance, as a courtesy, we will bill your insurance carrier directly. Dental insurance rarely covers 100% of services rendered; therefore please be prepared to pay your co-pay at each visit. South Waterfront Dental is happy to provide an estimate for your co-pay prior to your visit. This is an estimate only and you will be responsible for any amounts not reimbursed by your dental insurance.
Scheduled appointments are reserved specifically for you. If you need to change an appointment, please contact the office with at least 48 hours notice. There will be a $25.00 fee for appointments cancelled without 48 hour notice. There will be a $50.00 fee for not showing for a scheduled appointment.
We realize that time is very important to you, and we make every effort to stay prompt. We ask that you have the same consideration by being on time for your appointments.
Please do not hesitate to ask any questions you may have concerning office policies. We welcome open communication with you and wish to develop a relationship of friendship and trust. Our goal is to meet your dental needs while offering you the most comfortable and enjoyable dental experience.

Patient's signature(Required)

By typing your full name here, you are electronically signing this document.

First Last

Please select today's date(Required)

TMJ & bruxism treatment

Root canal therapy

Tooth-colored fillings

Teeth whitening

Porcelain veneers

Same-day crowns

Dental crowns

Dental bridges

Dental implants

SureSmile

Dental Insurance 1st Coverage

Dental Insurance 2nd Coverage (if different then primary)

Authorization

Consent

Financial Agreement & Cancellation Policy

Get comprehensive, compassionate dental care on your time