New Patient Form

Name

First Last

Birthdate

Social Security Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Responsible Party

Is the responsible party different from the patient?

Yes

Name of ther person responsible for this account

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

SSN

Birthdate

Primary Insurance

Name of policy holder

First Last

Relationship to Patient

Self

Spouse

Child

Other

Birthdate of Policy Holder

Employer

Insurance Company

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Plan Name

Subscribe ID# or SSN Of Policy Holder

Additional Identifiers

Previous Dentist

Date of last dental exam

Date of last x-rays

Emergency Contact Name

First Last

Emergency Contact Phone

Who can we thank for referring you?

Please initial to show that you have read and agree to the statements below:

Authorization and Release

I authorize and request my insurance company to pay directly to Rockhouse Dentistry. 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.

Cancelation Notice

If you are unable to keep your appointment, notify us as soon as possible. Any patient that misses an appointment without 24 hours’ notice may be charged a $100 fee.

Monthly Statements

Statements will be sent monthly showing your current balance. After 90 days, your account will incur a Finance Charge at 18% annual interest.

Attorney Fees and Costs

In the event my account is turned over to an attorney for collection, I agree to pay an attorney's fee equal to 33 1/3% of the account balance turned to the attorney for collection or $400 whichever may be greater. Additionally, I agree to pay all costs of filing suit, service of process, and other similar costs, as may be determined by the court.

HIPAA

I have been given the opportunity to read the notice of privacy practices containing a more complete description of the uses and disclosures of my personal health information. Rockhouse Dentistry is authorized to release and/or request information that may be necessary for either treatment or billing purposes. The following family members are authorized to receive personal health information from this office:

Authorized Family Members

Please List names and relationships

Do You Have Active Tuberculosis

Yes

Are you under a physicians care now?

Yes

Do you have a persistent cough lasting longer than 3 weeks?

Yes

Are you in good health?

Yes

Do you have a cough that produces blood?

Yes

Do you use controlled substances?

Yes

Have you been exposed to anyone with tuberculosis?

Yes

Do you drink alcoholic beverages?

Yes

Are you allergic to any of the following?

Please explain your allergy

Please indicate if you have ever had the following

Congenital Heart Disorder

Artificial Heart Valve

Previous infective endocarditis

Damaged valves in transplanted heart

Unrepaired, cyanotic CHD

Repaired (completely) in the last 6 months

Repaired CHD with residual defects

Other diseases and conditions

Women: Are you

Pregnant

Nursing

Taking birth control/hormonal replacement

Please indicate if you have ever had the following

Today's Date

Signature

Contact Info

Phone:
208-356-5600
Email:
rockhousedentistry@hotmail.com
Address:
106 E. 1st North
Rexburg, ID 83440

Hours of Operation:

Monday: 8am - 5pm
Tuesday: 8am - 5pm
Wednesday: 8am - 5pm
Thursday: 8am - 5pm
Fridays: 9am - 2pm

New Patient Form

Contact Info

Hours of Operation:

Payment Methods

Social Media

CollectJS Payment Form