Sante Fe Dental Online Patient Forms

Patient History

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  • Dental Insurance Info

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  • Medical History

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  • Dental History

  • Circle all that apply
  • Authorization and Release

  • In accordance with the Privacy Rules of HIPAA and with my understanding of the Patient Notice that I have read, I am hereby giving my full consent to Santa Fe Dental to maintain my medical/dental records, transmit, forward and or release information about me, my health information and/or my Personal Health Information to any applicable person(s) or agencies, provided it is in my best interest and/or for the advancement or continuance of any health care services which I am being treated. I have read and answered the above questions to the best of my knowledge. I understand that I am ultimately financially responsible for all charges. By signing below I acknowledge my understanding of all terms and conditions.
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  • Financial Policy

  • Your financial responsibilities are not only important to you; they are also an essential part of your care and treatment. Should you have any questions about our financial policy, please do not hesitate to ask.

    Payments are due in full at the time of service and can be made in the form of:

    • Cash
    • Check
    • All Major Credit Cards (American Express, Discover, MasterCard, or Visa)
    • Care Credit

    When your portion of the investment is $500.00 or greater, Santa Fe Dental requires a 20% deposit to schedule the appointment. This deposit is refundable up until 48 hours prior to your appointment. Patients may also receive a five percent discount on the total investment amount if paid in full at least one day prior to the appointment.

    Recommendations for your care are based on the needs of your oral health and not on your insurance benefits. However, we will try our best to work with you to maximize your insurance benefits so you can have a treatment plan that fits within your budget.

    You are responsible for the total treatment fee. As a courtesy to you, we accept assignment of benefit payments from most insurance companies. We are happy to assist you with your insurance; however, your co-pay is due the day services are rendered. If you do not inform us of any special requirements in your plan, and the service we perform is denied, you are responsible for paying for the treatment. We allow 90 days for your insurance company to make a payment. At this time all unpaid balances become your responsibility.

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  • Cancellation Policy

  • When you schedule an appointment at Santa Fe Dental, we reserve a specific time-slot and chair just for you. In order to best serve our patients, Santa Fe Dental requires a 48 hours notice for any changes to your appointment. This includes cancellations, no shows and rescheduling. This gives us the appropriate amount of time to fill your reservation. Patients who are unable to honor the 48 hours notice will be charged a $45.00 per hour fee to their account. This fee is not applicable to an appointment that requires a deposit as stated in the Financial Policy as this deposit would then be non-refundable.

    To avoid any unwanted charges to your account, please be sure to contact our office at (405) 844-6100 at least 48 hours prior to your reserved appointment time.

    I acknowledge and agree to the terms of Santa Fe Dental’s Cancellation Policy.

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