New Patient Establishment Form

Dental Insurance
Do you have dental insurance?*

YesNo
Primary Dental Insurance Information
Name of Dental Insurance Company*
Dental Insurance Company Location*
Policy Holder Relationship to Patient*
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Phone Number*
Insurance Subscriber ID #*
Insurance Group/Policy #*
Upload Image of FRONT of Primary Dental Insurance Card

Browse Files

Cancelof
Upload Image of BACK of Primary Dental Insurance Card

Browse Files

Cancelof
Name of Employer*
Employer's HR Dept Phone #*
Insurance Company Phone #*
Do you have Secondary Dental Insurance?*

YesNo
Secondary Dental Insurance Information
Name of Dental Insurance Company*
Dental Insurance Company Location*
Policy Holder Relationship to Patient*
Policy Holder Relationship to Patient*
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Phone Number*
Insurance Subscriber ID #*
Insurance Group/Policy #*
Upload Image of FRONT of Secondary Dental Insurance Card

Browse Files

Cancelof
Upload Image of BACK of Secondary Dental Insurance Card

Browse Files

Cancelof
Name of Employer*
Employer's HR Dept Phone #*
Insurance Company Phone #*

	Yes
AIDS
Allergies (Medicines)
Allergies (Pollen/Dust)
Alzheimer's Disease
Anemia
Angina/Chest Pain
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Bacterial Endocarditis
Blood Thinner
Bloody Sputum
Breathing Problem
Bruise Easily/Blood Disease
Cancer
Chemotherapy
Clotting Problems
Cold Sores
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Deaf
Diabetes
Drug Addiction/Alcoholism
Emphysema
Epilepsy or Seizures
Ever taken fen-phen?
Excessive Bleeding
Excessive Thirst
Fainting or Dizziness
Fever Blisters
Frequent Cough
NONE OF THE ABOVE

	Yes
Frequent Diarrhea
Genital Herpes
Glaucoma
Gout
Hay Fever
Head Injuries
Headaches/Tension
Heart Attack/Failure
Heart Disease/Surgery
Heart Murmur
Heart Pacemaker
Hemophilia
Hepatitis A (Infectious)
Hepatitis B or C
Herpes
High Blood Pressure
HIV Positive
Hives or Rash
Hypoglycemia
Intestinal Problems
Irregular Heart Beat
Jaundice
Kidney Disease
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Lupus
Mental Disorders
Migraines
Mitral Valve Prolapse
Nervous Disorders
NONE OF THE ABOVE

	Yes
Nervousness
Night Sweats
Pain in Jaw Joints
Parathyroid Disease
Pre-Medication
Psychiatric Care
Psychiatric Problems
Pulmonary Shunt
Radiation Treatments
Recent Blood Tranfusion
Recent Weight Loss
Renal Dialysis
Respiratory Problems
Rheumatic Fever
Rheumatism
Scarlet Fever
Shortness of Breath
Sickle Cell Disease
Sinus Trouble
Special Diets
Stomach/Intestinal Problems
Stroke
Swelling of Limbs
Thyroid Disease
Tuberculosis
Tumors or Growths
Ulcers
Unexplained Fever
Urinary Problems
Venereal Disease
X-Ray Treatments
Yellow Jaundice
NONE OF THE ABOVE

Assignment of Benefits
I understand I personally owe any amount, in whole or in part, for which the insurance carrier does not reimburse Atlanta Dental Center.
Patient or legally authorized individual signature*

Clear
Date*

MonthDayYear
Date
Relationship to patient if signed by anyone other than the patient (e.g. parent, legal guardian, etc.)
Notice of Privacy Practices & Patient Acknowledgment
PATIENT ACKNOWLEDGMENT OF PRIVACY PRACTICES.
Patient or legally authorized individual signature*

Clear
Date*

MonthDayYear
Date
Relationship to patient if signed by anyone other than the patient (e.g. parent, legal guardian, etc.)
Financial Policy & Policy Regarding Dental Insurance
FINANCIAL POLICY
POLICY REGARDING DENTAL INSURANCE
Patient or legally authorized individual signature*

Clear
Date*

MonthDayYear
Date
Relationship to patient if signed by anyone other than the patient (e.g. parent, legal guardian, etc.)
Photographic/Media Release
Patient or legally authorized individual signature

Clear
Date

MonthDayYear
Date
Relationship to patient if signed by anyone other than the patient (e.g. parent, legal guardian, etc.)

Payment of New Patient Special Reservation & Visit Fee

$50 total to reserve the New Patient Special appointment. There are no additional charges for the New Patient Special Visit. See further details under section "Authorizations and Acknowledgements".

New Patient Special Reservation and Visit Fee$50.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Authorizations and Acknowledgements

By clicking the submit button below, I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

By clicking the submit button below, I authorize the diagnosis of my dental health by means of radiographs, study models, photophraphs, or other diagnostic aids deemed appropriate.

By clicking the submit button below, I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

By clicking the submit button below, I authorize my payment details listed above to be charged for a non-refundable new patient reservation fee of fifty ($50.00) dollars. I further understand that this reservation fee only covers some or all of the following services as determined by the doctor. Services potentially covered are ADA Codes D0150, D0181, D0210, D0330, D0350, D0367. I further acknowledge that the reservation fee does not cover any other kind of dental work. The reservation fee cannot be paid by dental insurance and is not combinable with dental insurance.

By clicking the submit button below, I acknowledge that a doctor-patient relationship has not been established with any of the practitioners or staff or legal entities emlployed by or associated with the Atlanta Dental Center, LLC and Atlanta Dental Center, PC. (A doctor-patient relationship can become established when the patient has been seen by the doctor.)

By clicking the submit button below, I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).
BEFORE CLICKING SUBMIT - After you click submit, wait for our website to load (atlantadentalcenter.com). Once our website has loaded, your information has been sent. Thank you!
Should be Empty:

	Yes	No	Unsure
Have you ever had braces?
Do you think you have active decay?
Do you think you have active gum disease?
Do you have frequent bad breath?
Do you brush your teeth routinely?
Do your gums ever bleed?
Do you like your smile?
Do you floss your teeth routinely

	Yes	No	Unsure
Do you brux or grind your teeth?
Does your jaw joint make popping sounds (or similar)?
Are there any sores or growths in your mouth?
Do you use tobacco products?
Do you want to keep your remaining teeth?
Does food catch between your teeth?
Do you have any loose teeth?

New Patient Establishment Form

* = Required Field

Dental Insurance

Dental & Medical History

DENTAL HISTORY

MEDICAL HISTORY

Assignment of Benefits

Notice of Privacy Practices & Patient Acknowledgment

Financial Policy & Policy Regarding Dental Insurance

Photographic/Media Release

Payment of New Patient Special Reservation & Visit Fee