1387 Castle Hill Avenue, Bronx, NY 10462 | 718-962-9324 | |

Online Welcome Form

    Welcome to Modern Smiles Dental Care

    Thank you for choosing our office. At Modern Smiles we strive to build long-term relationships with our patients where we provide quality, consumer-friendly dental services utilizing the latest dental technology that the whole family can value and afford in a safe and happy environment.

    Patient Information:

    If patient is a student:

    Primary Insurance:

    Secondary Insurance:

    In Case of Emergency:

    Dental History:

    Please check all that apply:

    Medical History:

    Please check all that apply:

    Notice of Privacy Practices & Authorization:

    By signing this form, you consent that you have read our posted notice of Privacy Practices (HIPPA) and understand it completely. I understand that I am authorizing the release of my records to third party payers, other healthcare professionals or operations, or other entities as deemed necessary by this office.

    I understand that I (or said dependent) have insurance coverage that will be assigned to the office for billing and payment. I understand that I am financially responsible for all charges whether they are paid by insurance or not, as well as any additional collection costs for balances payable over 60 days. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize my insurance company to make payments directly to the dental office for benefits otherwise payable to me. I authorize the use of this signature on all insurance submissions/claims.

    I understand that appointment times are specifically scheduled for ideal patient care and that last-minute cancellations and no-shows are subject to a $50 per occurrence fee. I understand that after several missed appointments the doctor may dismiss me as a patient of the practice.

    I authorize Modern Smiles Dental Care to confirm my appointments via phone, email and text messaging confirmations. I further authorize being contacted about special services, events of new health information on behalf of the dental office via phone message, text message,and email.

    I have reviewed the information on this form, and it is accurate to the best of my knowledge.

    I will inform this office of any changes in my health status. I understand that dental treatment and local anesthesia entail risks such as bleeding, infection, nerve damage, or fracture of teeth or bone. I certify that the above information is complete and accurate to the best of my knowledge.