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Patient Information

Marital Status
Have you or a member of your family been a patient at this office before?
Otherwise, how did you learn about our practice?

Account Responsible Party

Currently a patient in our office(s)?

Primary Dental Insurance

Will you be using dental insurance?

If you answered yes, please fill out the following:

Effective Date

Dental History

Please check any of the following problems that apply to you:
If you could whiten your teeth for a cost you could afford, would you do it?
If you could change anything about your smile it would be:

Medical History

Please check any of the following that APPLIES TO THE PATIENT:
Do you use any recreational drugs?

To the best of my knowledge, I have answered every question completely and accurately. It is my responsibility to inform the dental office of any changes in my health and or medications.


HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described in this authorization. 

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be as effective as to the disclosure of records whose released I have previously authorized, or where other action has been taken in  reliance on an authorization I have signed. I understand that my health care and the payment for my health care will not be affected if I refuse to sign this form. 

I understand that information used or disclosed, pursuant to this authorization, could be subject to redisclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

Financial Agreement

Our primary goal is to not allow the cost of treatment to prevent you from benefiting from the quality care you need or desire. In our office, we strive to maximize your insurance benefits and make any remaining balance easily affordable. 

Our fees are based on the quality materials we use and the time, effort, and skills required in performing your needed treatment. We charge what are the usual and customary fees for our area. We will assist you with your benefit eligibility before treatment to help you calculate your costs and maximize your insurance. We will be sensitive to your financial circumstances and do everything possible to help you achieve oral health. Ultimately, however, you are responsible for payment regardless of any insurance 

company’s arbitrary determination of usual customary rates. 

We are happy to submit the claims necessary to see that you receive the full benefits of your coverage; however we cannot guarantee any estimated coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all changes. Please know that we will do everything possible to see that you receive the full benefits of your policy by electronically filing your claim the day of your appointment. 

  • Please have your current Insurance ID Card and Driver's License available at each visit so we can avoid filing errors. Errors and changes in policy coverage prevent us from filing your insurance with only a policy number and company name, therefore, we will not file insurance for you without a copy of your current ID card. If at any time your insurance should change, our office must be notified immediately of the change to accurately file change. 

Patients are expected to pay for their services at the time they are rendered.  Payments may be made using cash, check, Visa, MasterCard, American Express, Discover and/or CARECREDIT. CARECREDIT is a financing option that is available only for healthcare expenses allowing patients to extend payments out over a series of months.

  • Our patients who have dental insurance are expected to pay the amount of their estimated co-pay, deductible, and remaining balance at the time of service. 

  • The cost of dental care is determined by the nature and complexity of your visit. There is no “flat rate” for examinations and treatment. Insurance is a contract between you and your insurance company. As a service to you, our office makes every reasonable effort to obtain payment according to your coverage. Regardless of the type of insurance coverage you have, you are ultimately responsible for paying your medical bills. If your insurance company rejects the claim or delays payment, the office will bill you after the rejected charges. It is at all times your responsibility to follow up on all requests from your insurance company regarding claims and to question your insurance company about any unpaid claims. 

  • Self-pay patients will be expected to pay in full at time of service. 

  • The responsibility for payments for services rendered to any dependent children whose parents are divorced or separated rests with the parent who seeks treatment. Any court ordered responsibility judgment must be determined between the individuals involved without the inclusions of our office.   

  • A $35.00 service charge will be applied to your account for all returned checks. 

  • Our office policy is to charge a patient $50.00 for any hygiene appointment that is not cancelled within 24 hours. All procedural appointments scheduled with a doctor that are not cancelled within 24 hours will be charged $100.00. Please help us serve you better by keeping scheduled appointments.

  • Transferred x rays will be charged a transfer fee of $125.00 prior to release.

Thank you for reading and cooperating with the policies at Shady Oak Dental LLC. It is our hope that the above financial policy will allow us to provide quality care to our patients. If you have any questions or need clarification on any of the above policies, please do not hesitate to contact our Business Office.


I agree to abide by the terms of the above financial policy and accept responsibility for any balance not covered by my insurance company; therefore, I authorize my insurance company, attorney, or other parties to pay directly to Shady Oak Dental LLC and/or provide any information regarding payment of my bill. Balances due on my account shall be paid in full on current statement.  If my account becomes delinquent, I agree to pay all costs incurred in collecting the account, including court and attorney fees. 

I authorize the doctor in charge to administer medical care as necessary, including allowing release of records or medical reports on my physical condition to any party involved in my treatment

Date of Birth
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