Urgent Smiles Solutions

Thank you for your interest in our services. Please fill out the form so we can better assist you. You will receive a response within 30 minutes from 8 am-9 pm daily.

Patient Registration

Date*

First Name*

Last Name*

Date of Birth*

Street # and Address*

City*

State*

Zip Code*

Email*

Cell Number*

Phone

Health Information

Dental Problem or Emergency*

Medical History have you ever had*

if none apply, type "none"

Select or enter value

other medical conditions*

if none apply, type "none"

allergies*

if none apply, type "none"

What medications are you taking?

HIPAA Acknowledgement

This HIPPA notice will be reviewed with you at the office.

HIPPA & Informed Consent*

HIPAA Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that:  Protected health information may be disclosed or used for treatment, payment, or healthcare operations.  The practice reserves the right to change the privacy policy as allowed by law.  The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.  The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.  The practice may condition receipt of treatment upon execution of this consent. This is my digital Signature (Type Your First Name and Last Name and Today's Date)

HIPAA Compliance Patient Consent Form.

(X) Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

(X) The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

(X) The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

(X) You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations.

(X) We are not required to agree with this restriction, but if we do, we shall honor this agreement.

(X) The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

(X) By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication.

(X) You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

(X) By signing this form, I understand that:

(X) Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

(X) The practice reserves the right to change the privacy policy as allowed by law.

(X) The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

(X) The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

(X) The practice may condition receipt of treatment upon the execution of this consent.

(X) This is my digital Signature (Type Your First Name and Last Name and Today's Date)

My SIgnature and Date*

By Typing my name and date below I acknowledge the HIPAA Informed Consent

Financial & Insurance Acknowledgement

Financial Agreement & Credit Card Authorization*

I understand that I am responsible for payment of services rendered and also responsible for payment of fees that are not paid by my insurance. I understand that the $50 booking fee is a portion of the balance that will be due after necessary treatment is rendered. I will be responsible for all fees associated with the recovery of my delinquent account balance with Urgent Smiles Solutions.

(X) I authorize Urgent Smiles Solutions to charge the credit card that I provided for any remaining balance after services are rendered. Fees for services will be presented to me prior to the charge.

(X) I understand that I am responsible for payment of services rendered and also responsible for payment of fees that are not paid by my insurance.

(X) I understand that the $50 booking fee is a portion of the balance that will be due after necessary treatment is rendered. I will be responsible for all fees associated with the recovery of my delinquent account balance with Urgent Smiles Solutions.

(X) This is my digital Signature (Type your First Name and Last Name and Today's Date)

My Signature and Date.*

By Typing my name and date I acknowledge the Financial Agreement and my obligation. (Type Your First Name and Last Name and Today's Date)

Do You want to be Seen in Person or TeleDent*

Select or enter value

Other Comments

Forms and Required Files

Do You Have Dental and/or Medical Insurance*

Please select which benefits you have or if you do not have insurance select "Self-Pay".

Select

File Upload*

If you want us to bill your dental and medical insurance please submit by uploading your

1. dental insurance card (front and back),

2. medical insurance card (front and back),

3. your driver's license for Patient ID purpose Your booking fee and registration fee via Paypal of $150 will be applied towards any fees for today's visit. The billing team will file claims for you and we will resolve any balance once the claims pay.

Drag and drop files here or

After submission of this form, please proceed to the link below to pay for new patient registration

Our team will respond by calling you at the phone number you provided after we receive your registration fee.

Thank you so much for choosing Drs. Juan & Dorothy Kassab with your dental care.

If you have any questions, please call 315-697-9287

New Patient Registration Link

Send me a copy of my responses

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