New Patient Form

  • Welcome to StarWhite Dental

    So that we may better serve you, please take a few minutes to fill out the New Patient questionnaire, health history and applicable consent forms. This will help us prepare for your visit and make your experience more enjoyable, prompt and efficient. Please answer the following questions to allow for a more thorough evaluation and therefore a more effective treatment.
  • Personal Health Information and Privacy (HIPPA)

  • To the Use and Disclosure of Health Information for Treatment, Payment or Dental Care Operations, I understand that as part of my health care, StarWhite Dental originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

         • A basis for planning my care and treatment.

         • A means of communication among the many dental/health professionals who contribute to may care.

         • A source of information for applying my diagnosis and treatment information to my bill.

         • A means by which a third-party payer can verify that services billed were actually provided.

         • A tool for routine dental care operations such as: assessing quality and reviewing the competence of dental/healthcare professionals.

    I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:      • The right to review the notice prior to signing this consent.

         • The right to object to the use of my health information for directory purposes.

         • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations.

    I understand that StarWhite Dental is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

    I further understand that StarWhite Dental reserves the right to change their notice and practices, prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should StarWhite Dental change their notice, they will send a copy of any revised notice to the address I have provided via US Mail or Email if I agree.

    I understand that as part of this organization’s treatment, payment or health care options, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax transmission.

  • Patient Information

  • Phone Numbers

  • Dental Insurance

  • Assignment and Release
    I certify that I, and/or my dependent(s), have insurance coverage and assign directly all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
    The dentist may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
  • Dental History

  • Health History

  • Signature