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Patient Information

NAME

DOB / PREFERRED PRONOUN

ADDRESS

CITY / STATE / ZIP

EMPLOYER / WORK PHONE

OCCUPATION / S.S.#

HOME PHONE / CELL PHONE

REFERRED BY

IN CASE OF EMERGENCY NOTIFY

1. NAME / PHONE

2. NAME / PHONE

PERSON RESPONSIBLE FOR ACCOUNT PAYMENT IF OTHER THAN PATIENT

NAME

S.S.#

RELATIONSHIP TO PATIENT / HOME PHONE

ADDRESS IF DIFFERENT

CITY / STATE / ZIP

EMPLOYER / WORK PHONE

hereby authorize the office of Lonestar Endodontic Associates to discuss my treatment and financial information with

(Name of person to discuss information with)

( for example a friend , spouse or relative). I understand that by signing this release form I am complying with HIPAA Privacy Laws. The person(s) I listed above has my permission to discuss my personal dental information.

Sign:

Click to Sign

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

AUTHORIZATION AND MEDICAL RELEASE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group, insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient (or parent/guardian if minor)

Click to Sign

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

IS THERE ANY OTHER INFORMATION THAT SHOULD BE KNOWN ABOUT YOUR HEALTH OR ABOUT PREVIOUS DENTAL VISITS?

M. Scott Monts, D.D.S., M.S.
Rajesh V. Shenoy D.D.S.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

* You May Refuse to Sign This Acknowledgment*

have received a copy of this office’s Notice of Privacy Practice. You can ask for a paper copy of this notice at any time.

Signature

Click to Sign

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

Cancellation Agreement

Please read and initial

Initial

Click to Sign

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

Please be on time for all appointments. Root canal therapy is time-consuming. If you are late by as much as 15 minutes, we may not have time to finish your case and will have to re-appoint you. Your appointment is a contract for our time. If you cannot make a scheduled appointment, PLEASE CALL US AT LEAST 24 HOURS BEFORE so that we can let someone else have your appointment time. FAILURE TO DO SO WILL RESULT IN AN ADDITIONAL CHARGE OF UP TO $200 for the time you reserved. If you have a Monday appointment and cannot make it, you may contact our office at info@lonestarendo.com or call 512-450-1750 no later than noon Sunday to avoid charges.

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Patient Information

Patient Information

IN CASE OF EMERGENCY NOTIFY

PERSON RESPONSIBLE FOR ACCOUNT PAYMENT IF OTHER THAN PATIENT

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AUTHORIZATION AND MEDICAL RELEASE

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PATIENT MEDICAL HISTORY

PATIENT MEDICAL HISTORY

PLEASE CHECK Yes or No

Why are you here?

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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Cancellation Agreement

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Main Header

Patient Information

Patient Information

IN CASE OF EMERGENCY NOTIFY

PERSON RESPONSIBLE FOR ACCOUNT PAYMENT IF OTHER THAN PATIENT

Click to Sign

AUTHORIZATION AND MEDICAL RELEASE

Click to Sign

PATIENT MEDICAL HISTORY

PATIENT MEDICAL HISTORY

*****PLEASE CHECK Yes or No*****

Why are you here?

Click to Sign

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click to Sign

Cancellation Agreement

Click to Sign

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