Lake Mary: New Patient Form

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  • Welcome to Smile Design!

  • Patient Information (Confidential)

















  • Your e-mail address is used for appointment reminders, monthly promotions, follow ups, and newsletters. If at any time you wish to OPT out of any or all of these services, please contact the office.

  • Insurance Information

















  • Patient Medical History

  • Condition Year  

  • Patient Dental History


  • CONSENT

    • hereby authorize the doctor and/or staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis.
    • 2. I authorize the doctor to perform all recommended treatment mutually agreed upon. I also agree to the use of appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk.
    • 3. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine. As stated in the “Payment Policy” form, payment is due and payable at the time services are rendered unless other arrangements have been made. (See form for additional information).
    • 4. I understand that a $50 fee per 30 minutes for the duration of your appointment time reserved, will be assessed to your account for any missed appointments. Should I need to cancel or change any appointment, I understand that I need to give the office 48 business hours notice.
    • 5. I understand that it is my responsibility to advise your office of any changes in the information contained in this form.

  • Release of Information Consent Form

  • I
  • have read and understood the HIPAA Notice of Privacy Practices that was provided to me by Smile Design Dentistry. However, In the event that I may need them to do so, I grant permission for Smile Design Dentistry and or staff to: (Please Check one of the following):
  • (initial)
  • (initial)
  • (initial)
  • (initial)

  • Smile Design Dentistry

  • Cosmetic and Family Practice

    Our Policy of Care and Payment

    Ensuring that our patients receive high quality care is the goal of our practice! We strive to see every patient on time, however emergencies can delay the schedule occasionally. We thank you for your understanding.

    Payment Options

    • Cash or Check
    • Debits Cards (with Visa/MasterCard logo)
    • Major Credit Cards (MasterCard, Visa, Amex, Discover)
    • HSA/Flex Spending Debit Cards (with Visa/MasterCard logo)
    • Care Credit (interest free financing available)
    • Citi Bank Health Card
    • Lending Club
    • Simple Pay

    Applying for Care Credit and similar Payment Plans only takes a few minutes, and there is NO fee to apply.

    Broken Appointments

    Please call the office 48 hours (business days) in advance if you need to change or cancel your appointment with our office. We understand that there extenuating circumstances at times but this will allow us to better serve other patients needing to get an appointment and is greatly appreciated. A $50.00 set up and sterilization or broken appointment fee may be assessed if the appointment is broken without notice.

    Insurance Agreement

    This agreement is made between the undersigned patient below and Smile Design Dentistry. This form must be read and signed by the patient or the responsible party before the practice can accept payments directly from your insurance carrier.

    • Patient/responsible party understands and agrees that he/she is responsible for all treatment fees on the patient’s account regardless of insurance estimates.
    • Patient/responsible party understands and agrees that if for any reason your insurance carrier fails to pay the estimated portion that you are responsible for all balances on the account.
    • Balances over 90 days are subject to be placed in collection’s that will include a 33% admin fee.

    We accept and file insurance as a courtesy to our patients and insurance estimates are not a guarantee of payment by your insurance carrier. All insurance policies are not the same and it is the patient/responsible party’s responsibility to understand their policy.

  • Patient/Responsible Party Signature
  • Date

  • Smile Design Dentistry

  • Cosmetic and Family Practice

    Patient Consent for Use of Credit Cards, Debit Card, and Financing
    Disclosure of Protected Health Information

    It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies, when requested, to facilitate your payment.

    Services that are performed that are paid with a credit card, debit card, or financing third-party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Smile Design Dentistry to use and disclose my protected health information to any Credit Card Entity, Bank or Financing Company when they request such information to process an account and assist with payment.

  • I will not challenge such credit, debit, or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise.
  • I agree that this non credit card challenge agreement is irrevocable.
  • Signature of Patient or Legal Guardian
  • Date

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