New Patient Forms | Scottsdale Surgical Arts

Personal Info

Insurance

Health History

Allergies & Meds

Consent & Sign

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Thank you! Your new patient forms have been received by our team. We'll review your information before your appointment and reach out if we have any questions.

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Personal Information

Fields marked * are required.

Last Name *

First Name *

Middle Initial

Date of Birth *

Gender

Male Female Other

Marital Status

Single Married Partnered Other

Social Security Number Used only for insurance claim filing. Never shared.

Nickname / Preferred Name

Contact & Address

Home Address *

City *

State

Zip Code

Mobile Phone *

Home Phone

Email Address *

Work Phone

Additional Information

Employer / Responsible Party

Referred By

Driver's License Number

DL State

Emergency Contact

Emergency Contact Name *

Relationship

Phone *

Step 1 of 5

Insurance Information

Enter your primary insurance. Add secondary if applicable.

Primary Dental Insurance

Insurance Company

Employer / Group

Group / Policy Number

Insurance Phone

Insurance Address

City / State / Zip

Employee (Subscriber) Name

Subscriber Date of Birth

Member ID / SSN (for claims)

Patient's Relationship to Subscriber

I have a secondary dental insurance plan

Secondary Dental Insurance

Insurance Company

Employer / Group

Group / Policy Number

Insurance Phone

Employee (Subscriber) Name

Subscriber Date of Birth

Member ID / SSN (for claims)

Patient's Relationship to Subscriber

Step 2 of 5

Allergies & Medications

Please indicate any allergies and list all current medications.

Allergies — indicate Yes or No for each

Aspirin

Codeine

Erythromycin

Latex

Penicillin

Sulfa Drugs

Local Anesthesia

Other Allergies

Current Medications

List all medications, vitamins, and supplements you currently take.

Step 4 of 5

Consent & Signature

Please review and agree to the following policies before submitting.

Payment Policy — Please Select One

Self-Pay Payment is due in full at the time of service.

Primary / Secondary Insurance We will bill your insurance as a courtesy. Co-pays and deductibles are due at time of service. Any balance unpaid after 30 days is the patient's responsibility.

Cancellation Policy

Please read carefully: All patients who fail to arrive for their scheduled appointments or do not give 24 hours' advance notice will be charged a missed appointment fee.

• 30-minute to 1-hour appointment — $50.00
• 1-hour+ appointment — $100.00

This fee is not covered by insurance and is your personal responsibility. If you miss three appointments without advance notice, any remaining appointments will be cancelled.

HIPAA — Patient Information Consent

I hereby authorize Scottsdale Surgical Arts to request and receive the release of any protected health information regarding my treatment, payment, or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information.

Authorized parties who may access my health information:

Name

Relationship

Name

Relationship

Treatment Consent

I understand that the information I have given is correct to the best of my knowledge. 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. I authorize the dental staff to perform the dental services necessary for my oral health. I understand that payment is due in full at the time of treatment unless prior arrangements have been made.

24-hour notice required to cancel or reschedule without a fee.

Records Release (Optional)

If you'd like us to request your records from a previous dentist, complete this section.

Previous Dentist's Name

Practice Phone

Practice Fax or Email

Signature

By typing your full name below, you confirm that all information provided is accurate and that you agree to the policies above. This serves as your electronic signature.

Step 5 of 5

Complete Your Paperwork Online

Forms Submitted Successfully

Personal Information

Insurance Information

Dental & Medical History

Allergies & Medications

Consent & Signature

Ready to schedule your appointment?