Download New Patient Forms
PTS NOTICE OF PRIVACY PRACTICES CONSENT FORM
Download Medical Records Release Form
HIPPA NOTICE OF PRIVACY PRACTICES

New Patient Form

  • New Patient Form

    For your convenience, you can complete the new patient questionnaire below online and submit the form via e-mail.
  • If you have a Dental Benefits' Plan, do you need our help?

    If YES, Please provide us some information.
  • Although we can be reached by U.S. Mail, Phone, and even through our websites private messaging system, on occasion, an E-mail might be the best way to communicate... Please make a note of ours: Familydentalspa1@gmail.com
  • To learn more about us, we would also like to Invite you to visit BrandonDentalSpa.com (our website). as well as to "Like Us" on Facebook; each of those sites will convey additional useful information for you to enjoy and be shared with loved ones who you might think would benefit from it. We look forward to caring for your oral health and to continue earning your trust; the referrals of your friends and loved one will be your highest compliment and it will be very much appreciated AND acknowledged! Thank you!
  • Your insurance policy is a contract between you and your insurance company. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. Payment is due at time of service. We accept cash and all major credits cards. Any missed appointments without 24-hour notice, except in an emergency, will result in a charge of the patient. These charges are due and payable within 30 days.
  • Medical History

  • Click those that apply :
    By checking 'Agree' you agree the information provided is true and accurate to the best of your knowledge and you agree to inform this office in the event that information changes.
  • Dental History

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  • Family Dental Spa - Notice of Health Records Confidentiality and Financial Policy, Options & Agreement

  • Financial Policy, Options & Agreement:

    Thank you for choosing us for your dental care, we appreciate the opportunity to serve you! We are committed to providing you - and those you love - with excellent dental care, and we realize a frank discussion of recommended treatment options, respective fees, and patient's financial capabilities & obligations prior to dental treatment helps relieve some of the anxiety associated with dental visits. Our fees are based on the quality of the products and materials we use and on our experience in performing each procedure. On of our goals in NOT to allow expenses to be the factor that might prevent you from experiencing the benefits of optional dental health or a confident smile, therefore, in respect to payment options, billing and/or insurance coverage, and to confirm your understanding and agreement with our policies, please read the following:
  • Patients WITH insurance benefits, please not that unless a previously discussed financial arrangement is in place, the estimated patient's co-pay and deductible for the treatment rendered must be paid in full on the day of service. Please understand that you are ultimately responsible for all fees generated by your treatment.
  • Patients WITHOUT insurance benefits, please not that unless a previously discussed financial arrangement is in place, the fee for the treatment rendered must be paid in full on the day of services.
    By checking 'Agree' you agree the information provided is true and accurate to the best of your knowledge and you agree to inform this office in the event that information changes.
  • Informed consent

  • I hereby authorize my dentist, and whomever he/she may designate as his/her assistants and/or hygienists, to perform upon me those dental procedures which we have discussed, and I have accepted in the treatment plan. If any unforeseen condition arises in the course of these designated procedures calling, in their judgment, for procedures in addition to or different from those now contemplated, I further request and authorize whatever he deems advisable.
  • I consent to the treatment plan I have accepted after having been advised of alternate plans of treatment available.
  • I am informed to: post-treatment pressure and temperature sensitivity, pain or throbbing, pupal inflammation, fracturing of new restorations due to early biting pressures, tenderness of abutment teeth, tenderness of tissues under removable dentures, post-operative pain and throbbing, swelling and reinfection, fracturing of files or the crown portion of the tooth during and following root canal therapy, sensitivity of the teeth and gums during and following dental cleanings.
  • The most common of these complications in oral surgery include post-operative bleeding, swelling, or bruising, discomfort, stiff jaws, and loss or loosening of dental restorations. Other less common complications include, but are not limited to: infection, loss or injury to adjacent teeth and soft tissues, jaw fractures, sinus exposure and swallowing or aspiration of teeth and restorations, nerve disturbances (e.g. numbness in mouth and lip tissues), and small root fragments remaining in the jaw which might require extensive surgery for removal. These complications may be temporary or permanent.
  • I further consent to the administration of any drugs that may be deemed necessary in case, including, but not limited to: local anesthetics, antibiotics, and analgesics. I understand that there is a slight element of risk inherent in the administration of any drug of anesthesia. This risk includes, but is not limited to, the following complications: adverse drug response (e.g. allergic reactions), cardiac arrest, thrombophlebitis, (e.g. irritation and swelling of a vein), aspiration, pain, discoloration, and injury to blood vessels and nerves which may be caused by injections of any medications or drugs.
  • A more complete explanation of all complications is available to me upon request from my Doctor.
  • I am aware that, in spite of the possible complications and risks, my treatment is necessary and desired by me. I realize that the practice of dentistry is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of the procedures.