Online Forms

Welcome Form

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  • WHO MAY WE THANK FOR INVITING YOU TO OUR PRACTICE ?

  • Telephone

  • When is the best time to reach you?

  • :
  • Emergency contact

  • Responsible Party (if someone other than the patient)

  • Date Format: MM slash DD slash YYYY
  • Insurance Information

  • Primary Dental Insurance

  • Secondary Dental Insurance

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  • Authorization and Release

    The following release will allow us to share pertinent information regarding your care to enhance your treatment and/or financial reimbursement for services received:

  • 1. I authorize Lisbon Smiles to share information regarding my course of treatment and the services received with my referring medical and dental providers in order to enhance my continuing treatment and care.
  • 2. I authorize Lisbon Smiles and/or any other provider or supplier of services in this office to release any information required to secure payment for services received or the payment of benefits on my behalf. I authorized the use of the signature on all insurance submissions.
  • 3. I understand that I am financially responsible for all charges, whether paid or not by insurance, and for all services rendered on my behalf or on behalf of my dependents.
  • 4. I acknowledge I have received a copy of this office’s Notice of Privacy Practices.
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  • Financial Arrangements

  • If I do not pay the entire new balance within 30 days of the monthly billing date, a late charge of

    1.5% on the balance then unpaid and owed will be assessed each month. I realize that failure to keep this account current may result in you being unable to provide additional dental services unless arrangements have been made. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

  • Date Format: MM slash DD slash YYYY
  • Thank you for filling out this form completely. The information you have provided will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at any time, please ask - we are always happy to help.

 

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