• Canyon Crest Dental - New Patient Registration

    • About You 

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    • Neighbor or Relative not living with you

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    • Spouse Information 
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    • Insurance Information 

    • Primary Insurance

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    • Primary Medical Insurance


    • Secondary Insurance

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    • Secondary Medical Insurance


    • Dental History 

    • Notice of Privacy Practices and Dental and Medical Information Release Form (HIPAA)

    • I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA") I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

      * Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.

      * Obtain payment from third-party payers.

      * Conduct normal healthcare operations such as quality assessments and physician certifications.

      I understand that I can receive your complete Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

    • Thank you for choosing our office to meet your dental needs.

      We make every effort to give the perfect patient experience. For your comfort we offer nitrous oxide (laughing gas) and sedation dentistry. Please let us know if you would be interested in either of those options. We also have pillows, blankets, TV's, music and wireless earphones available. Shortly after completing your professional cleaning or treatment with the Dr. you will be provided with a warm towelette.

      To assure that you receive the best dental care in an efficient and timely manner we reserve appointments exclusively for you. If you need to change or cancel an appointment please notify us within 48 hours to avoid a $75.00 cancellation fee. If an appointment is cancelled or failed multiple times a deposit may be required to reserve your future appointments.

      We strive to provide excellent customer service and satisfaction. If you ever feel that you were given less than excellent service, we ask that you inform us immediately. Your feedback is important to us.

      We look forward to serving you and appreciate your patronage.

    • Dental insurance is a contract between the patient or employer with the insurance company. The dental office has no control of payments or reimbursement by the insurance company. We will make every effort possible to assist you with your particular coverage. Although it is not required, we will prepare and submit your insurance claim at no cost as a courtesy to our patient. We will also provide an "ESTIMATE" of cost that is due at the time of treatment. Should our "ESTIMATE" be too high, a refund will be issued. Likewise, if the "ESTIMATE" was low, the remainder will be due at that time. Should no insurance payment be made within ninety days of a submitted claim, the fee will become the sole responsibility of the patient.

    • Medical History 
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    • Our Office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
    • Authorization 

    • Medical History Update

    • As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

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    • If you are completing this form for another person, what is your relationship to that person?

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    • Please stop and return this form to the receptionist.

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    • WOMEN ONLY

      Are you
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    • Allergies

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    • NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

      I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form

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