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Tin Wai Hui, DMD PA & Associates 16209 NE 13TH Avenue 600 S. Dixie HWY #105A 17901 NW 5th St. #206 12651 S. Dixie HWY #400No. Miami Beach, FL 33162W. Palm Beach, FL 33401Pembroke Pines, FL 33029 Pinecrest, FL 33156 305.940.9888 561.820.8898 954.430.2188 305.595.4548 □North Miami Beach □West Palm Beach □Pembroke Pines □Pinecrestleft59055E-mail:_____________________________________________________ Today’s Date:_________________________00E-mail:_____________________________________________________ Today’s Date:_________________________*PATIENT’SNAME:________________________________________________________________________________ (First) (MI) (Last) Street Address___________________________Apt___________City___________________State________Zip ________Home#_____________________________Cell#____________________________Work#__________________________Social Security #__________________________________ Drivers License#_____________________________________ *required* Occupation_________________________________________Employer________________________________________Date of Birth_____/_____/_____ Age_______ Height_______ Weight:_______ Gender: Male / Female (Month/Day/Year) (Please circle) *Emergency Contact:________________________ Relationship: _____________________*Phone:________________ If you are completing this form for another person, what is your relationship to that person?Your Name:_______________________________________________ Relationship:_____________________________214630414020Whom may we thank for referring you to our office: (Please check all that apply)___Magazine ___Brochure ___Television/Radio ___Drive by/Location ___Insurance ___Online___Zoc Doc ___Groupon___Facebook ___Referred by________________________________ ___Other______________________________________________ (Please specify name) 00Whom may we thank for referring you to our office: (Please check all that apply)___Magazine ___Brochure ___Television/Radio ___Drive by/Location ___Insurance ___Online___Zoc Doc ___Groupon___Facebook ___Referred by________________________________ ___Other______________________________________________ (Please specify name) Primary reason for this dental appointment: __Examination __Emergency __Consultation __Other_______________*RESPONSIBLE PARTY (if other than the patient) Name_____________________________________________________________Relationship______________________(First) (MI) (Last) Street Address _________________________________________City___________________State________Zip________Telephone: Home__________________________ Cell__________________________ Work_______________________ *INSURANCE INFORMATION INSURANCE SUBCRIBER____________________________________________________________________Last Name First Name MI____________________________________________________________________Street City State Zip Code____________________________________________________________________Home # Work # Email____________________________________________________________________Birth Date (Mo/Day/Year) Relationship to Patient____________________________________________________________________Employer Dental Insurance Company____________________________________________________________________Social Security # Subscriber/Member ID # Group #RELATIONSHIP TO SUBSCRIBER __SELF __SPOUCE __CHILD __Other____________________________________________________________________Last Name First Name MI____________________________________________________________________Street City State Zip Code____________________________________________________________________Home # Work # Email____________________________________________________________________Birth Date (Mo/Day/Year) Relationship to Patient____________________________________________________________________Employer Dental Insurance Company____________________________________________________________________Social Security # Subscriber/Member ID # Group #We are happy to file insurance claims and assist you in obtaining the maximum benefits specified in your contract. 1. We will do our best to ESTIMATE your coverage, and file your insurance on your behalf. Please be aware that your dental benefit program is a contract between you, possibly your employer, and the Insurance Company. We are not a party to that contract. We file insurance claims as a courtesy to you, our valued patient.?You are responsible (not your insurance company) for all fees for services rendered. We will gladly assist you in any way we can.2. Our office policy states that you are responsible for your bill. The ESTIMATED patient portion of the fee is due at the time of service. If a balance remains after we receive payment from your insurance carrier within 30 days we will notify you. Failure of your insurance carrier to reimburse our office within 30 days will result in our billing you directly for the remaining balance and will be subject to a 1.5% monthly interest or 18% APR, late fee together with expenses incidental to collection, including reasonable attorney’s fees and cost.3. We are committed to providing the highest quality of care. Our treatment recommendations and the dental services we provide are in the best interest of the patient's health. The patient is responsible for payment in full regardless of an insurance company's arbitrary determination of treatment necessity. 4. If your coverage changes for any reason, please notify the office immediately. By signing this form, you have read and understand our policy. Any denials or insurance payments less than estimated will be your responsibility. Payment will be due upon our billing cycle. All estimated out of pocket fees and deductibles are due the day of treatment. Ask our office regarding our In House Dental Insurance and financial options before your visit, or if you have any questions regarding your insurance and our policy. -15240076200I hereby acknowledge that a copy of this office’s Payment and Refund Policy has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.Signature X _____________________________________________________________Date______________________ 00I hereby acknowledge that a copy of this office’s Payment and Refund Policy has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.Signature X _____________________________________________________________Date______________________ X _______________________________________________________________ ______________________________(Signature) (Date) * APPOINTMENT POLICY 1. You will receive a reminder 1-3 days prior to your appointment. Patients are kindly asked to confirm at least 24 hours prior to the scheduled appointment. Appointments can be confirmed by responding within the electronic notification, calling the office, or on the website contact page. Please Initial Here: ________ 2. We require forty-eight (48) hours advance notice of cancellation. Patients who do not provide forty-eight (48) hours notice of cancellation or do not present for a scheduled appointment may be charged a fee. This fee will vary depending on the amount of time scheduled and will not be less than $30.00. Patients who fail to present for two (2) appointments risk being dismissed from the practice. Please Initial Here: ________-149225236855State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. Our Notice is available to you. Please ask one of our staff for a copy of our Notice. I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.Signature X _____________________________________________________________Date______________________ 00State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. Our Notice is available to you. Please ask one of our staff for a copy of our Notice. I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.Signature X _____________________________________________________________Date______________________ center462center429My Dental GOALS are:□ Whiter Teeth □ Full Dentures □ Partials □ Pain Free □ Cavity free □ Better chewing □ Straighter Teeth □ Better Breath □ Botox □ Healthier gums □ Less Bleeding □ Fillers □ Replacing Missing Teeth □ Decrease Sensitivity □ Other:_________________1. Why did you leave your other dental practice? __________________________________________________________ 2. What do you expect from our practice? _______________________________________________________________ 3. When was the last time you were seen by a Dentist? ____________________________________________________ 4. May we take dental x-rays on you if they are needed? Yes No 5. Do you take fluoride supplements? Yes No 6. Have you ever had periodontal treatment (gum treatment)? Yes No 7. Do you floss regularly? Yes No 8. Do your gums bleed when you brush or floss? Yes No 10. If you had a magic wand, what would you change about your smile? ______________________________________________________________________________________________________________________________________________________________________________________________ In an effort to provide you with flexible payment arrangements, we have expanded our payment policy. PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT. We now offer the following payment options:____Payment by cash ____Payment by check ____ Payment by Credit Card ____Financing from 3rd Party____Payment Plan ____Other:______________________________________________________________Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program, which will enable you to use your Visa and MasterCard to automatically cover amounts not paid by your insurance.If none of the above apply, please request to see someone.___________________________________ ___________________________________________________Print your name aboveSign your name aboveDateThank you for taking the time to complete these new patient forms. We personalize your dental care based on the answers you’ve provided ................
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