New Patient Information Forms
Sunrise Dental provides comprehensive patient information forms, including sections for personal details, dental and medical history, insurance agreements, and office policies. The forms emphasize the importance of accurate information, patient responsibility for insurance coverage, and adherence to appointment and financial policies.
Download All Documents in One File
This button allows you to download all required documents in one file.
Information/Dental History
- Collects personal details: name, address, contact information, date of birth, social security number, and driver's license.
- Asks for employment details and emergency contact information.
- Asks about the last dental visit and reasons for it.
- Includes questions about periodontal disease, gum bleeding, removable dental appliances, and previous dental treatment issues.
- Inquires about current pain, discomfort, and other dental concerns.
Medical History
- Collects information on physician care, hospitalizations, head injuries, medications, and special diets.
- Asks about the use of tobacco, controlled substances, and specific medications like Phen-Fen or Fosamax.
- Includes a comprehensive list of medical conditions for the patient to check if applicable.
Patient Insurance Agreement
- States that insurance coverage is an agreement between the patient and the insurance carrier.
- Emphasizes patient responsibility for knowing their insurance policy and covering any unpaid balances.
- Requires patient acknowledgment of the information provided.
Authorization for Release of Information
- Allows patients to specify entities authorized to receive their health information.
- Informs patients of their rights to revoke authorization and the potential for re-disclosure of information.
Notice of Privacy Practices
- Requires patient acknowledgment of receiving the office's Notice of Privacy Practices.
- Includes a section for office use if acknowledgment cannot be obtained.
Office Policies
- Cancellation Policy: Requires 48 hours' notice for appointment changes, with a $25 fee for late cancellations.
- Appointment Deposit Policy: Requires a $100 deposit for appointments of 90 minutes or more, non-refundable if canceled with less than 48 hours' notice.
- Filing of Dental Insurance: States that insurance coverage is the patient's responsibility, with charges unpaid by insurance within 45 days becoming the patient's responsibility.
- Financial Agreements: Payment is due at the time of service, with various payment options available.
- Insufficient Funds / Returned Checks: A $35 fee for returned checks.
- Treatment Plan Reports: Estimates are subject to change after 90 days.