New Adult Patient Registration Form

PATIENT INFORMATION
WORK INFORMATION
INSURANCE INFORMATION
If covered under spouse’s plan as secondary coverage:
MEDICAL HISTORY
Have you had an allergic or unusual reaction to any of the following?
(Leave blank if all answers are No)
FOR WOMEN ONLY
Have you ever been treated for any of the following?
(Leave Blank if all answers are No)
Please answer all questions below:
Dental History
PLEASE READ THE FOLLOWING CAREFULLY
Office Policy
  • We will gladly complete Dental Insurance Claim Forms with the following understanding;
    a) The patient is financially responsible for the entire cost of the treatment.
    b) Payment is to be made to “Dental Land Professional Corporation” by the patient or by direct billing to the insurance company.

iTrans
  • Benefits payable from claims submitted electronically will be assigned to Dental Land and payment will be received by the Dentist directly.
CANCELLATION/ NO SHOW POLICY
  • At least 24 hours notice is required if you must cancel/reschedule your appointment for any reason.
  • Missed Appointments will incur a firm charge of $50.00
  • All outstanding fees must be paid in full before further appointments will be booked.
  • Should you miss an appointment, it is your responsibility to call and rebook.
  • Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.
Statement of Understanding
I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Dental Land Professional Corporation's policy and understand that breaching it in anyway may result in disciplinary action.

Schedule Appointment

Fill out the form below, and we will be in touch shortly.
Contact Information
Medical Condition
Preferred Date and Time Selection