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Patient Forms 480-838-3315 Tempe

Patient Forms

One smile at a time

Patient Forms

If you are a new patient to our office, we invite to you fill out and submit the new patient forms below. This will help streamline your initial visit, feel free to contact us is you have any questions while filing the forms out.

New Patient Adult – Full

New Patient Child – Full

Medical Health History Update

Contact us today!

APPOINTMENT
CONTACT US

Our Practice

  • About PFD
  • Meet The Team

Patient Info

  • Patient Forms
  • Financial Policies

Testimonials

  • Testimonials
  • Reviews

Gallery

  • Smile Gallery
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Contact

  • Contact Us
480-838-3315 Tempe
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New Patient Full - Child r1

Step 1 of 4

25%

  • Patient Information

  • Parent/Guardian Information

  • Insurance

  • Insurance Details

  • Dental History

  • Health History

  • Have you child ever had any of the following disease or medical problems?

  • In order to serve you better, please describe any current medical treatment including medications, pending surgery, recent injuries or any other information that our office should be aware of.
  • I hereby authorize the dentists and staff of Pospisil Family Dentistry to perform diagnostic aids including an examination, x-rays, photographs, models, cleaning and fluoride treatment when necessary as the standard of care to properly diagnose and record any and all dental conditions. (Please cross out any treatment that you do not want performed). I authorize my insurance company to pay Pospisil Family Dentistry all insurance benefits otherwise payable to me for treatment rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance, all broken appointment fees, late payment service charges and any collections fees. I also understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of Pospisil Family Dentistry. This consent is to remain in effect from the date indicated until cancelled in writing.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

    Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • My Personal Information

  • Emergency Contact

  • Primary Care Physician

  • Primary Care Physician Details

  • Preferred Pharmacy/Drugstore

  • Other Physicians

  • Click the + icon at right to add rows.
    NameSpecialtyPhone Number 

  • My Allergies

  • My Medical Conditions

  • Medications

    Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
  • Click the + icon at right to add rows.
    What I'm takingForm (pill, injection, etc)DosageHome much and whenUse (regularly or occasionally)Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing)Notes, directions, reasons for use 

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

    Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • General Release of Information

    I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes]

  • Person(s) authorized to receive your information:

  • How to Contact

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

    When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.

    Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

    Insured Patients:

    As a courtesy, we will process your insurance claims for you. Please understand the following:

    1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
    2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
    3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
    4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
    5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
    6. All charges are your responsibility regardless of any insurance benefits.

    All Patients:

    Please be aware of the following:

    1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
    2. The charge for each returned check is $50.00.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • This field is for validation purposes and should be left unchanged.

Medical Health History Update

  • Please note any changes in your Medical Health

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.
  • This field is for validation purposes and should be left unchanged.

New Patient Full - Adult

Step 1 of 4

25%

  • About You

  • Account Responsibility

  • Account Responsibility Details

    Not the patient, please fill out all fields below.

  • Spouse Information

  • Insurance

  • Insurance Details

  • Neighbor or Relative not living with you

  • Personal Physician

  • Personal Physician Details

  • Physician Care

  • Have you ever had any of the following disease or medical problems?

  • Are you allergic to any of the following?

  • Birth Control/Pregnancy

  • Pregnancy Details

  • Dental History

  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

    Payment is due in full at the time of treatment unless prior arrangements have been approved.

    If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs fo dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

    Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • My Personal Information

  • Emergency Contact

  • Primary Care Physician

  • Primary Care Physician Details

  • Preferred Pharmacy/Drugstore

  • Other Physicians

  • Click the + icon at right to add rows.
    NameSpecialtyPhone Number 

  • My Allergies

  • My Medical Conditions

  • Medications

    Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
  • Click the + icon at right to add rows.
    What I'm takingForm (pill, injection, etc)DosageHome much and whenUse (regularly or occasionally)Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing)Notes, directions, reasons for use 

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

    Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • General Release of Information

    I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes]

  • Person(s) authorized to receive your information:

  • How to Contact

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

    When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.

    Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

    Insured Patients:

    As a courtesy, we will process your insurance claims for you. Please understand the following:

    1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
    2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
    3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
    4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
    5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
    6. All charges are your responsibility regardless of any insurance benefits.

    All Patients:

    Please be aware of the following:

    1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
    2. The charge for each returned check is $50.00.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • This field is for validation purposes and should be left unchanged.

Office Policies

  • Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

    When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time.

    Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

    Insured Patients:

    As a courtesy, we will process your insurance claims for you. Please understand the following:

    1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
    2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
    3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
    4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
    5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
    6. All charges are your responsibility regardless of any insurance benefits.

    All Patients:

    Please be aware of the following:

    1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
    2. The charge for each returned check is $50.00.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • This field is for validation purposes and should be left unchanged.

Medication & Personal Information

  • My Personal Information

  • Emergency Contact

  • Primary Care Physician

  • Pharmacy/Drugstore

  • Other Physicians

  • Click the + icon at right to add rows.
    NameSpecialtyPhone Number 

  • My Allergies

  • My Medical Conditions

  • Medications

    Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
  • Click the + icon at right to add rows.
    What I'm takingForm (pill, injection, etc)DosageHome much and whenUse (regularly or occasionally)Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing)Notes, directions, reasons for use 
  • This field is for validation purposes and should be left unchanged.

New Patient - Child

  • Patient Registration

  • Other electronic forms of communication are used in our office. Should you wish to take advantage of these; please fill out the area provided.

  • In an effort to improve communications with our patients our office will email and or text appointment reminders. Please enter your information below to participate with these services.

  • Insurance

  • Insurance Details

  • Dental History

  • Health History

  • In order to serve you better, please describe any current medical treatment including medications, pending surgery, recent injuries or any other information that our office should be aware of:
  • I hereby authorize the dentists and staff of Pospisil Family Dentistry to perform diagnostic aids including an examination, x-rays, photographs, models, cleaning and fluoride treatment when necessary as the standard of care to properly diagnose and record any and all dental conditions. (Please cross out any treatment that you do not want performed). I authorize my insurance company to pay Pospisil Family Dentistry all insurance benefits otherwise payable to me for treatment rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance, all broken appointment fees, late payment service charges and any collections fees. I also understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of Pospisil Family Dentistry. This consent is to remain in effect from the date indicated until cancelled in writing.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • This field is for validation purposes and should be left unchanged.

New Patient - Adult

  • About You

  • Account Responsibility

  • Account Responsibility

    Not the patient, please fill out all fields below.

  • Spouse Information

  • Insurance

  • Insurance Details

  • Neighbor or Relative not living with you

  • Medical History

  • Have you ever had any of the following disease or medical problems?

  • Are you allergic to any of the following?

  • For Women

  • Dental History

  • Affirmation

    I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

    Payment is due in full at the time of treatment unless prior arrangements have been approved.

    If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs fo dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

    Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • This field is for validation purposes and should be left unchanged.

Dental Information Release Form (HIPPA Release)

  • General Release of Information

    I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes]

  • Person(s) authorized to receive your information:

  • How to Contact

  • Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

  • This field is for validation purposes and should be left unchanged.