Patient Registration

Last name

First name

Birthday

Month

Day

Year

Gender

Multi-line address

Country/Region

Address

City

Zip / Postal code

Cell Phone

Other Phone

Preferred Contact Method

Ok to text?

If you are filling this form out for someone else, what is your relation?

Nickname or preferred name you would like us to use

In case of an emergency, who may we contact?

Relation to Patient

Phone

What is the reason for your visit to our office?

How did you hear about our office?

Who can we can thank for your referral?

PRACTICE POLICIES ACKNOWLEDGEMENT & CONSENT TO TREATMENT

Appointments

I understand that my appointment times are reserved for me, and if I fail to keep my appointment, or cancel with less than 2 business days, I may be required to pay a non-refundable deposit in order to reserve future appointments.

Financial

I understand that payment is expected as services are rendered unless prior financial arrangements have been made.

I understand that for services requiring the use of a third-party lab, I will be responsible for the lab fee at the time the prosthesis or appliance is delivered unless prior financial arrangements have been made.

I understand that Cornerstone Family Dental is not contracted with any insurance or other benefit companies, nor are they responsible for billing any insurance or other benefit companies on my behalf.

I understand that I will be supplied with information pertaining to my treatment that I can submit on my own to any insurance or other benefit companies upon request.

I understand that if I take part in the membership plan at Cornerstone Family Dental, I cannot submit for reimbursement to any insurances or other benefit companies.

Warranty

I understand that the following warranty only applies if I am a patient of record at Cornerstone Family Dental and comply with the recommended exam and cleaning schedule.

For any failure due to defect in material or workmanship, the following applies:

Crowns, Bridges, Implants: 5 years
Fillings: 5 years, unless otherwise stated by dentist
Appliances made in office: 5 years for splints, 2 years for all others
Appliances made by third-party lab: 5 years for non-interim dentures and partial dentures

For any defect due to negligent care or accident, the following apply:

Crowns: 5 years – 50% off regular fee plus any lab fee
Fillings: 5 years, unless otherwise stated by dentist – 50% off regular fee
Appliances made in office: 5 years for splints, 2 years for all others – 50% off regular fee
Appliances made by third-party lab: 5 years for non-interim dentures and partial dentures – 50% off regular fee plus any lab fee

I have read and filled out this Patient registration and Consent Form to the best of my knowledge and it is complete and correct. I am consenting to treatment and agree to pay for all services rendered.

Signature

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