Welcome to Great Northern Dental Care. We look forward to serving you!

New Patient Information

______? Female ? Male

Patient Name Preferred Name Date of birth SS#

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Mailing Address City State Zip code

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Home phone Cell phone Work phone E-mail

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Emergency Contact Relationship Phone Number

Marital status: ? Single ? Married ? Widowed

To confirm appointments, we may text or email you. Please let us know if you prefer something different.

Insurance Benefit Information–please let us know if you have more than one dental insurance.

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Policy holder’s name DOB SS#

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Insurance Company Name Employer ID# Group#

Privacy Practices–Acknowledgement of Notice of Privacy Practices

I understand that Great Northern Dental Care, PC abides by the HIPAA Law and will protect the privacy of my personal information. I have been given an opportunity to read Privacy Practices. I authorize the release of information to other health care providers and insurance carriers as it relates to my care. I understand that I may refuse to sign this acknowledgement.

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Please Print Name Signature Date

Disclosure of Private Information to Persons other than Patient

I authorize Great Northern Dental Care to disclose my protected health information to the following people. I understand this authorization is for an indefinite amount of time unless otherwise noted. Please note relevant friends, spouses, parents, grandparents, etc.

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Name Relationship

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Name Relationship

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Please Print Name Signature Date

How did you hear about us? We would like to thank them. ______

Thanks for choosing Great Northern Dental Care. We look forward to serving you and working with you to obtain optimal oral health. Our goal is to treat everyone with kindness and respectwhile providingexceptional care. The following office policies will help us serve you better.

Appointment Policy

  • Please confirm your appointments. To reserve time just for you, we must hear from you at least the day before your appointment. You can respond to our texts or give us a call.
  • Please be a few minutes early to your appointments.
  • If something comes up and you are not able to keep your appointment, please give us at least 1-2 days’ notice.
  • We may be unable to reserve future appointments if there is a history of failed appointments or last-minute cancellations.
  • If your contact information changes, please let us know as soon as possible, so we can contact you regarding your appointments.

Financial Policy

Payment in full or patient portion (if there is insurance) is due at time of service. To make this as convenient as possible for our patients, we have several options.

  • Checks, cash, and all major credit cards are accepted.
  • Care Credit is accepted - a deferred interest health credit card. If paid on time, you pay 0% interest. You can apply by calling 866-893-7864 or on-line at CareCredit.com
  • Pre-payment Plan - send or call in payments at your convenience in advance of treatment.

In the event a balance becomes past-due, the account may be sent to an outside collection agency. You will then be responsible for the balance due, plus the cost of collections (up to 45% of the balance).

Dental Insurance

As a courtesy to our patients, we file insurance claims for our patients. Since insurance companies only give us general information regarding benefits, we encourage you to understand your dental benefits. In most cases, patient portions are only an estimate. Please understand, you are responsible for the entire balance not covered by your insurance carrier.

I have read and agree to the terms of Great Northern Dental Care’s financial and appointment policies.

Patient or Legal Guardian Name

Signature