Have you or anyone close to you experienced flu-like symptoms within the past 14 - 21 days such as:

New Patient Information

About You

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Dental Insurance Information

Primary Insurance

Secondary Insurance

IN CASE OF EMERGENCY, WE SHOULD NOTIFY

MEDICAL HISTORY

DO YOU HAVE OR HAVE YOU EVER HAD

DO YOU HAVE OR HAVE YOU EVER HAD:

ARE YOU:

List all medications, supplements, and or vitamins taken within the last two years

APPOINTMENT POLICY

When you make an appointment with our office,we consider this a mutual commitment and reserve appropriate facilities and staff exclusively for you.In our office policy states that patient must give us 1 business day or 24 hours notice if they cannot keep an appointment.Late notice or missed appointment may be subjected to a minimum $60 charge

FINANCIAL POLICY

General Consent to Treatment

I Agree and consent to a dental examination by Hardik Patel. I Understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.Also I acknowledge that there are no guarantees,expressed or implied, as to the result of any procedures or dental treatments performed.

Release of Information

I authorize Smiles by Dr. Patel to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.

Assignment of Insurance Benefits

I authorize and request my insurance company to pay my benefits directly to Hardik Patel.

I understand and comply with the office Appointment policy.

I understand and agree to the General consent to treatment.

I authorize the Release of Information.

I authorize the Assignment of Insurance of Benefits.