A Beautiful Smile Makes A Lasting Impression

Located at: 8350 East Raintree Drive Suite 115 Scottsdale, AZ 85260     Call Us to Schedule an Appointment Now! 480-609-0050

Belmont Dentistry

Located at:
8350 East Raintree Drive Suite 115
Scottsdale, AZ 85260

480-609-0050

Fax: 480-609-0047
E-mail: belmontdentistry@qwestoffice.net

We Accept Most Dental Insurance

Hours: Mon - Fri 9 a.m. - 6 p.m. Saturdays By Appointment Only

If this consent is signed by a personal representative on behalf of the patient, please complete the following:

Downloadable Forms

Dear Friends,

Although it can be difficult, we do our very best to accommodate every patient’s individual needs and work schedules. We also work hard to stay on schedule so as to minimize your waiting time in our office.

A schedule appointment of time is made between Belmont Dentistry and you. We have reserved that time just for you. When appointment are missed or canceled, that time is lost.

We ask that when you schedule your treatment, you make every effort to keep that commitment. We do understand that personal emergencies arise and we take that into consideration.

However, if you find that you cannot keep your scheduled appointment, a 24-hour notice will allow us to schedule another patient in need of treatment.

Our policy is that a fee of $45.00 will be applied to your account if an appointment is cancelled with less than 24 hours notice. If any appointment is cancelled with less than one-hour notice, a fee of $90.00 will be applied.

If you have further questions regarding this or any other policy or procedure, we are more than happy to discuss them with you.

Thank you for your understanding and cooperation.

Sincerely,

Belmont Dentistry

New Patient Form

Please print, fill out, and bring the New Patient Form with you when you visit our office. Form is also available as a PDF file: New Patient Form PDF.

Belmont Dentistry

Statement on HIPPA: Health Insurance Portability and Accountability Act

In 1996, The U.S. Congress mandated the Health Insurance Portability and Accountability Act which became effective April 14, 2003. It was designed to protect the confidentiality of patients’ medical information that has, in the past, been shared between health insurance plans, banking establishments and employers. Prior to the passage of the law, this information could have been, and sometimes was, used to the detriment of the patient / client.

As a covered entity by definition of the law, our office must abide by the laws set forth in this legislation.

Here at Belmont Dentistry, we look at these changes not as something to be threatened by, but a mechanism to protect consumer health information. It is our intention to abide by the law to our utmost ability. Our privacy policies are currently as the law requires.

We release no personal patient information to any outside source except regarding procedures done in this office for dental insurance compensation, or if a patient requests that we file forms for them. If any other information is requested outside of the normal information requested by insurance companies for processing of claims, our policy is to require your written permission to release such information. At the present time, this office does not file any claim forms electronically. However, we will hold that option open for future use.

Please remember that when information is submitted to the dental insurance companies for payment, that information falls under the HIPPA Act. Therefore, we must comply with the law by obtaining complete HIPPA forms from all patients. The added extra minutes that will be needed to fill out these forms are now necessary to protect you as the patient and us as the provider. Thank you for your cooperation.

Belmont Dentistry

Acknowledgement of receipt of notice of privacy practices and consent for use and disclosure of health information.

I have received and / or read a copy of this office’s notice of privacy practices.

I fully understand that this office will only release information that is pertinent to the processing of my insurance claims when applicable. If I have no insurance, there will be no release of any information unless to facilitate scheduling an appointment with a specialist and any information which is needed by that specialist regarding my situation.

I am fully aware that electronic filing to the insurance companies can be done now or in the future on my behalf by Belmont Dentistry.

I am aware that I have the right to file a complaint, request information on that complaint, or to change any information that is untruthful concerning my health history.

I am in consent with this office and their practices safeguarding my private health information according to the HIPPA rules and guidelines. I agree that this office will notify me of any further changes or requests regarding my personal health information.

We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.
Bold = Required field
Last Name:
First Name:
Middle Name:
Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
SS#:
DOB:
Marital Status:
Sex:
Employer Name & Address:
Referring Pt:

Primary Insurance Coverage

Referring Dr:
Subscriber Name & Address:
Relation to Patient:
SS#:
DOB:
Employer Name & Address:
Group #:
Family Yearly Deduct:
Individual Yearly Deduct:
Insurance Company Name & Address:
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment billing and processing of insurance for benefits for which I am entitled. I will not hold me dentist or any memeber of his / her staff responsibible for any effors or omissions that I may have made in the completion of this form.
Signature:
Date:

Responsible Party for Patient:

Personal Representative's Name:
Relationship to Patient:
Signature:
Date:
Financial Agreement:
I acknowledge that payment is due at the time of treatment,  unless other arrangement are made. I agree that parents / guardians are responsible for all fees and services rendered for treatment of a minor / child. I accept full financial responsibility for all charges not covered by insurance. In the event that account collection becomes necessary, the patient will be responsible for all collection costs, including attorneys fee.
Date:
Signature of Insured / Guardian:

Patient Medical History

Patient's Name:
ID:
For Office Use Only
Address:
Today's Date:
Date of Last Visit:
Date of Med. History:
City, State & Zip:
E-mail:
Home Phone:
Work Phone:
Birth Date:
Social Security No:
Marital Status:
Primary Dental Guarantor:
Home Phone:
Work Phone:
Work Phone:
Home Phone:
Secondary Dental Guarantor:
Physician Phone:
Physician Name:
Pharmacy Phone:
Pharmacy:
Medical Alerts:

For Office Use Only

Sex:

If female, please answer the following:

Are you pregnant?
Yes
No
No
Yes
Are you taking Birth Control Pills?
If Yes, # of Weeks:
Yes
No
Are you nursing?

Please answer the following:

Yes
No
Do you smoke or use tobacco?

For Office Use Only

BP
Heart Rate:
Height:
Weight:
Medications:
Is there any disease, condition, or problem that you think this office should know about that is not covered above? If yes, please describe below...
Yes
No
Describe:
Note:
Signature:
Date:

(If Under 18, Parent or Guardian Signature Required)

Conditions:
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artifical Heart Valve
Asthma
Blood Transfusion
Cancer-Chemotherapy
Congenital Heart Defect
Cosmetic Surgery
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Surgery
Hemophilla
Hepatitis A
Hepatitis B
High Blood Pressure
HIV+ AIDS
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Pneumocystitis
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Artificial Joints
Hepatiti C
Taken Fen-Phen
Allergies:
Aspirin
Codelne
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Name:
Signature:
Date:
Personal Representative's Name:
Relationship to Patient:
Patient Signature:

*Please fill out, print, and bring the above form with you on your next visit to our office.*

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