Make an Appointment with Chanhassen Family Dentistry
Chanhassen Family Dentistry
New Patient Form
  • Welcome to our office! Please tell us about yourself.

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  • Insurance - Primary * * * * * * * * * * * * * *

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  • Insurance - Secondary * * * * * * * * * *

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  • Medical History * * * * * * * * * *

  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrectinformation can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
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  • * * * * * * * * * * * * * * Dental History

  • * * * * HIPPA Privacy Practices

  • The Notice of Privacy Practices covers services provided to you by our office. We are required by law to maintain the privacy of protected health information and to provide you with the notice of our legal duties and privacy practices with respect to protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.The full document is available to you if you would like to review it.I acknowledge I have reviewed Chanhassen Family Dentistry's health information privacy and security policies and procedures.
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  • * * * * * * * * * * * *Financial Agreement

  • 8116 Mallory CourtChanhassen,
    MN 55317

    I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care, though it may not be included in my insurance contract.

    I authorize the release of any information concerning my (or my child's) health care, advice and treatment for the purpose of evaluating and administrating claims for insurance benefits or to another dentist or physician as may be medically necessary.

    I hereby authorize payment of the insurance benefits directly to Chanhassen Family Dentistry, P.A., otherwise payable to me.I understand that my dental insurance carrier or payor of my dental benefits may be less than the actual bill for services.

    I understand I am financially responsible for payment(s) in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor.

    I understand that my portion of the bill is due at the time services are rendered whether or not I carry dental insurance.

    I also understand that balances over 30 days are subject to finance charges as indicated on my statement. Balances over 90 days will be sent to another company to collect.

    I understand that there will be a thirty-five percent collection fee added to any account turned over to another company to collect due to non-payment to Chanhassen Family Dentistry, P.A.

    I understand that there will be a $30 service charge added to any returned payments.

    I understand that there may be a fee for cancelled or failed appointments without 24 hours notice.

    I authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
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