Main Header

Nerness Endodontics

Patient Information

WELCOME to our practice! Thank you for selecting our dental healthcare team and for filling out this form completely. The information you have provided will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at any time, please ask us for assistance. We are always happy to help.

Name

Prefix / Suffix / Nickname

Birth Date / Age / Social Security

Gender

Male Female

Address

City / State / Zip

Primary / Secondary Phone

Emergency Contact

Phone / Relation

Responsible Party (if different from above)

Name

Prefix / Suffix / Nickname

Birth Date / Age / Social Security

Address

City / State / Zip

Primary / Secondary Phone

HIPAA

To view a copy of Nerness Endodontics' Notice of Privacy Practices, click on the following link:
Notice of Privacy Practices

Nerness Endodontics’ Notice of Privacy Practices document is provided to you online and in our office.

I acknowledge that I have received a copy of Nerness Endodontics Notice of Privacy Practices I refuse to acknowledge that I have received a copy of Nerness Endodontics Notice of Privacy Practices

Health History

General Dentist Name

Referring Dentist (if different)

Medical Doctor Name / Phone

Clinic Name / City / State

Pharmacy / Phone

FINANCIAL AGREEMENT

This document represents a financial agreement between the undersigned responsible party and Nerness Endodontics.

Preferred payment method
(please select):

Cash Check Visa MasterCard Discover Care Credit American Express Cherry Varidi

• Insurance: As a courtesy to you, our office will submit your insurance claim on the day treatment is completed.

• Payment Plan: We have partnerships with CareCredit, Cherry, and Varidi; these options create flexibility for you to make small monthly payments. If you are interested in applying, a team member is happy to direct you to easily apply online.

• Payment Due: I agree to pay my preliminary payment on the day treatment is started. (A preliminary payment is required the day treatment is started. If you have insurance, this preliminary payment does not represent your final balance which cannot be determined until after your insurance company processes your claims.)

• Remaining Balance: I agree to pay all remaining balances regardless of insurance payment after my insurance company processes my claims. (Your insurance is an agreement between you and your insurance company. If you have a remaining balance due after your insurance company processes your claims, you are responsible to pay the remaining balance. If you have a credit balance after insurance claim(s) are processed, a refund check will be sent by mail.)

• Failure to Pay: Failure to pay on this account may result in me being unable to receive future services, a requirement for prepayment of future services, and my account being serviced by a collection agency.

• Broken Appointments: A $50 fee is may be assessed for appointments failed or cancelled with less than 2 days’ notice.

• Consent to Contact Responsible Party: I authorize Nerness Endodontics and/or their agents, for the purpose of servicing my account or to collect monies I may owe, to contact me by telephone at any number associated with my account, including wireless phone numbers which may incur charges by my wireless carrier. I authorize Nerness Endodontics to contact me by text message or any email address you provide. Methods of contact may include using pre-recorded/artificial voice messages and /or use of automatic dialing device, as applicable.

• Authorization for Release of Information and Payment: I authorize Nerness Endodontics, PC to release any Information to third party payers (e.g. your insurance company) and/or other health practitioners (e.g. your general dentist) including the diagnosis and the records of treatment or examination rendered to me during the period of such dental care. I authorize and hereby request my insurance company to pay directly to Nerness Endodontics, PC insurance benefits otherwise payable to me.

• Agreement to Pay: I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. I, the undersigned, accept fees charged as a legal and lawful debt and agree to pay the said fees for services provided. I waive now and forever my right of exemption under the laws of the constitution of the State of Minnesota and any other State.

By signing below, I confirm that the above information given in this document is true and complete and that I have read, understand, and agree to the financial policies.

Printed Name of Responsible Party

Signature of Responsible Party

Click to Sign

Date:-------------

truForm by PBHS

Main Header

Nerness Endodontics

Patient Demographics

Patient Information

Responsible Party (if different from above)

Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

HIPAA

Health History

Health History

Have you ever been diagnosed or treated for the following conditions:

Financial Agreement

FINANCIAL AGREEMENT

Click to Sign

Symptoms

Symptoms

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.

Main Header

Nerness Endodontics

Patient Demographics

Patient Information

Responsible Party (if different from above)

Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

HIPAA

Health History

Health History

Have you ever been diagnosed or treated for the following conditions:

Financial Agreement

FINANCIAL AGREEMENT

Click to Sign

Symptoms

Symptoms

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.