New Patient Form

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective treatment.

The Word Health Organization has characterized the COVID-19 virus, also known as "Coronavirus," as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation peroid. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious.COVID-19 can reult in a life0threatening respiratory disease in some patient(s). You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or "aerosols" which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposures. You cannot wear a procetice mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a save environment for out patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal procetion, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above that I understand and accept that there is an increased risk of COVID-19 esposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposures with treatment at this off ice.

I also acknowledge that I could, or may have exposure to COVID-19 from outside this office and unrelated to my visit here.

Please present insurance card to receptionist.

Please present insurance card to receptionist.

When a dental appointment is made in our pffice, a specific time is reserved for the patient to see the dentist or hygienist, and much time and preparation is providet to ensure a quality visit. Broken appointments result in a loss of valuable time that could be spent with patients in need of treatment and they are very costly to our office.

We make every effort to remind patients of their appointments including a text message, e-mail and telephone contact a few days prior.

If you need to cancel an appointment, 48 hours notice (business hours) is required to prevent a broken appointment charge of $50 from being applied to your account and due immediately.

For your convenience, we do have an answering machine available if you need to call after hours to cancel an appointment.

Thank you for your anticipated cooperation!

• For my convenience, this office may release my information to my insurance company, and receive payment directly from them.
• I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time.
• If sent to collections, I agree to pay all related fees and court costs.
• Every efort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible.
• I will be reposnible for insurance claims not paid within 54 days of service
• I agree to pay finance charges of 1.5% per mont (18% APR) on any balance 90 days past due.
• I will pay a $50 fee for appointments broken without 48 hours notice.
• Treatment plans may change, and I will be responsible for the work actually done.
• I give permission for my dentist and his/her clinical team to take any necessary x-rays, photos or study models to enable complete diagnosis and treatment.

For out patients with dental insurance, our professional services are render to you, not to your insurance company. Therefore, you are directly responsible to us for payment of treatment. As a courtesy, we do accept assignment of benefit payments from most insurance companies. This will reduce your immediate out-of-pocket expenditures. We will do our utmost to help you derive the maximum benefits to which you are entitled.

The insurance estimates we give you are based on limited information obtained from your insurance company. We allow 45 days for your insurance company to make payment. After this time, all inquiries or follow-ups on payments due become your responsibility.

I authorize the release of any information, including the diagnosis and the records od any treatment or examination rendered to my child or me during the period of such dentak care to third party payers and/or health practitioners. I also give Johns Creek Dental Studio PC permission to discuss or release my dental records to the names listed below.

The purpose(s) is/are providet so that I can make an informed decision whether to allow release of the information.

The Practise will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.

I do not have to sign this authorization to receive treatment from Johns Creek Dental Studio. In fact, I have the right to refuse to sign this authorization. Why my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipent and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the parctice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:

Johns Creek Studio
5455 McGinnis Village Pl,
Suite 103
Alpharetta, GA 30005

I have had full opportunity to read and consider the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.