Patient Registration

{ binding displayValue, mode=oneTime }

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Home Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Home Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Work Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Social Security Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Place of Employment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Occupation: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please upload a picture of your photo ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Emergency Information

Name of emergency contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address of emergency contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How did you hear about our office? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Dental Insurance Information (Primary Carrier)

Policy Holder's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy holder's date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy holder's social security number or member ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy holder's employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurace company address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurance Company Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please upload a photo of your insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please upload 2 photos (front and back)

Do you have secondary insurance coverage? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Secondary Insurance Coverage

This office bills primary insurance only

Policy holder's name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy holder's date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy holder's SSN or member ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy holder's employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurace company address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurance Company Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{# pageNumbers}

	Yes	No
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{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

	Yes	No
{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

	Yes	No
{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

Office Guidelines

Please review and sign below

We realize that every person's financial situation is different. For this reason, we have worked very hard to provide a variety of payment options to help you receive the dental care needed to enjoy a healthy and confident smile.

Payment Options

Cash or check: We are able to offer a 5% pre-payment courtesy for treatment under $1000.00, and 8% for treatment over $1000, and paid in full at the first visit.

Optional Payment Plan: If multiple appointments are required, your down payment is due when secure your appointment or at 1st appointment, and your final payment is due on or before your last appointment. Your Credit or Debit Card will be kept on file as a part of this payment option.

Extended Payment Plan: No interest payment plan offered by Care Credit. Payments are made directly to Care Credit for a period of 6 or 12 months. Application and approval through Care Credit is required. We can process your application today. If extending your payments past 12 months are important, please ask us about what else might be available to assist you with your dental care.

Dental Insurance

We are happy to file forms necessary to see that you receive the full benefits of your coverage, however, we cannot guarantee any estimated coverage. Unless prior arrangements are made you will be expected to pay the your portion as services are provided. Please keep in mind that we can only estimate your portion. If there is a difference after your insurance company has paid, it is yourresponsibility to pay the difference. Because the insurance policy is a contract between you and the insurance company, we will not enter into a dispute with your insurance company over your claim. We will provide information to support the necessity for treatment, which may assist you in recovering your benefits. Any unpaid balances greater than 90 days becomes the patient/guarantors’ responsibility.

Consent

I authorize the doctor to obtain x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis. I will be given the opportunity to discuss my treatment plan with the doctor and financial arrangements will be agreed upon before treatment is begun.

If care is being rendered on a minor child, I authorize the doctor to obtain x-rays and to treat my child as needed. I understand I will be given the opportunity to discuss the treatment with the doctor and that the parent or guardian who accompanies the child to office is responsible for payment.

Financial Responsibility

1.There is a $25 charge for all returned checks.

2.In the event of default I promise to pay legal interest on the indebtedness, collection cost, and related attorneys' fees.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please review and sign below

{# pageNumbers}

Patient Registration

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Home Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Home Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Work Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Social Security Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Place of Employment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Occupation: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please upload a picture of your photo ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Emergency Information

Name of emergency contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address of emergency contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How did you hear about our office? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dental Insurance Information (Primary Carrier)

Policy Holder's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy holder's date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy holder's social security number or member ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy holder's employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurace company address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Company Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please upload a photo of your insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Do you have secondary insurance coverage? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Secondary Insurance Coverage

Policy holder's name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy holder's date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy holder's SSN or member ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy holder's employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurace company address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Company Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Health History

Name of primary physician {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the reason for your visit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Last dental visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last dental x-rays {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last dental cleaning {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical History {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Health history

Medical History (continued) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list any other medical conditions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please indicate any allergies to: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other allergies {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What medications or supplements are you currently taking? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

For women only

Taking birth control pills {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many weeks pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Breastfeeding {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Office Guidelines

Payment Options

Cash or check: We are able to offer a 5% pre-payment courtesy for treatment under $1000.00, and 8% for treatment over $1000, and paid in full at the first visit.

Dental Insurance

Consent

Financial Responsibility

1.There is a $25 charge for all returned checks.

2.In the event of default I promise to pay legal interest on the indebtedness, collection cost, and related attorneys' fees.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

HIPAA Consent Form

The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal healthcare information is protected for privacy. The Privacy Rule was also created in order to provide a standard for health care providers to obtain their patient’s consent for uses and disclosures of health care information about the patient to carry out treatment, payment, or healthcare operations.

As our patient, we want you to know that we respect the privacy of your dental records and will do all we can to secure and protect that privacy. We will provide the minimum necessary information to only those who are in need of your health care information. This includes information about treatment, payment and/or health care operations in order to provide health care that is in your best interest.

We support your full access to your personal dental records. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, if you refuse to disclose you’re your Personal Health, we have the right to refuse to treat you. If you choose to consent, you may refuse all or part of your PHI at a future date. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions, and revoke consent in writing.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

COVID-19 Risk Acknowledgement

I acknowledge that COVID-19 is easily transmissible through dental aerosols. For my safety and the safety of others around me, I verify that I have not had COVID-like symptoms which include but are not limited to: coughing, shortness of breath, sore throat, runny nose or fever in the past 14 days. I also verify that I have no family members and have not had intimate contact with anyone who has had the aforementioned symptoms.

I understand that is impossible to completely eliminate the possibility of contraction of COVID at any dental office but I have been screened verbally, and had a normal temperature reading and I had a within normal limits blood oxygenation level.

Catonsville Dental Care has informed me of the inherent risks of dental treatment including the possibility of infection with COVID. Should I contract COVID, I authorize the release of that information to current staff members, any patients who may have been in proximity to me and to the Maryland Department of Health.

Catonsville Dental Care is upholding the highest standards of cleanliness and care, however, it is impossible to guarantee that transmission would not occur if undetectable. Infection with COVID can occur in any setting, and I hereby absolve Catonsville Dental Care of any responsibility if I test positive for COVID. I understand the risks and hereby consent to dental treatment.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }