New Patient Registration

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Patient Information

Medical Background

Medical Conditions

AIDS/HIV
Emphysema
Irregular Heartbeat
Anemia
Epilepsy/Seizures
Low Blood Pressure
Angina
Excessive Bleeding
Mitral Valve Prolapse
Arthritis/Gout
Fainting/Dizziness
Osteoporosis
Artificial Heart Valve
Heart Attack/Failure
Pain in Jaw Joints

Emergency Contact

How May We Contact You?

May we leave voicemails regarding appointments?
May we send emails regarding appointments?
May we send text messages regarding appointments?
May we release information to anyone other than yourself?
May we leave the above messages regarding sensitive financial or medical information?

The office of {Business name} is authorized to release protected health information about the above named patient to the entities named above. I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected. Patient Information I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to re-­‐disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.

Patient Information

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to re-­‐disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.

*If this form is being completed on behalf of a minor, a parent or legal guardian must complete and sign this form*

Insurance Information

Relationship to Policy Holder:

Employment Info

Employment:
Student Info:

By signing this document I agree {Business Name} to submit insurance claims on my behalf. I also agree that I am financially responsible for the account balance.

HIPAA

*See Notice of Privacy Practices*

I agree that I have received a copy of the Notice of Privacy Practices for the office of {Business Name}

Late/Broken Appointment Policy

We set aside specific time for each one of our patients to ensure we are able to provide quality dental treatment. We understand that situations arise in which you can’t make your scheduled appointment. We ask that you provide at least 24-­‐hour notice to change or cancel your appointment. By doing so, we can offer your time to another patient who is waiting to receive treatment. The lack of adequate notice is considered a no show.

TWO or more no shows and cancellations with less than 24-­‐hour notice may be subject to a $50 cancellation fee. Patients who do not show up or give adequate notice three (3) or more times may be dismissed from the practice and may be denied future appointments. Cancellation fees are the sole responsibility of the patient and must be paid in full before the next appointment.

We understand that special circumstances may cause you to miss your appointment or give adequate notice. Cancellation fees in this instance may be waived at the discretion of the doctors.

Financial Policy/Agreement

Please understand that all fees are given as an estimate based on your own insurance policy. We try our hardest to give you the most accurate patient portion, and even with a pre-­‐determination from insurance it is still only an estimate. We request all payment of patient portions be taken care of at the time of the appointment unless there are other financial arrangements made. {Business Name} must approve these financial arrangements in writing.

By signing this document I have read and understand the late/broken appointment policy and the financial policy/agreement.

If this form is being completed on behalf of a minor, a parent or legal guardian must complete and sign this form.

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Completed Projects

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#1

Dental Clinic

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15

IDIQ Experience

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We Boost Our Clients’ Bottom Line by Optimizing Their Growth Potential.

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Awards

Winner Seo Master MAGT Smart Start Award 2017

Top Social Media Agencies Next Partner 2018

10 Fastest Growing Abstract Solution Providers 2019

National Excellence Agencie Award Winner 2020

We Boost Our Clients’ Bottom Line by Optimizing Their Growth Potential.

We’re A True Partner

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Proprietary Processes

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Looking for more services?

“The team at Avada Marketing Consultant is fabulous. They helped us unlock our potential online and offline. We have experienced year on year growth due to their progressive approach.”

Melissa Dean

Marketing Consultant Expert