Cosmetic & Restorative Dentistry — A gentle touch. A beautiful smile.
Please complete all sections and sign where indicated. A copy will be sent to our office upon submission.
We are pleased to welcome you to our practice. Please fill out this form as completely as you can.
Please answer all questions completely and honestly. This information helps us provide safe and effective care.
By signing above, you confirm the medical history information provided is accurate and complete.
Help us understand your previous dental care so we can provide the best treatment possible.
Please read carefully and sign below to acknowledge that you have read and understood our office policies.
I authorize payment of dental benefits to Smile Design Center for services rendered. I understand that I am responsible for any balance not covered by my insurance.
Payment is due at the time of service. We accept cash, check, Visa, MasterCard, American Express, Discover, and CareCredit. For your convenience, you may also pay your bill online at pay.smiledesigncenterlv.com.
We kindly ask that you provide at least 48 hours notice to cancel or reschedule an appointment. Missed appointments or late cancellations may result in a cancellation fee of $50.
We will file your dental insurance as a courtesy. However, you are responsible for knowing your benefits. Any amount not covered by insurance is your responsibility and is due at the time of service.
We are committed to protecting your personal health information in accordance with HIPAA regulations. Please see our Privacy Notice for full details.
By signing above, you acknowledge that you have read, understand, and agree to the office policies above.
Please provide your primary and secondary insurance details. We will file as a courtesy on your behalf.
Please read the authorization for dental care carefully before signing.
I hereby authorize and consent to the performance of dental treatment, including but not limited to examinations, X-rays, cleanings, fillings, extractions, root canals, crowns, implants, and other procedures deemed necessary or advisable by Smile Design Center.
I authorize the taking of dental X-rays and other diagnostic images as deemed necessary by the treating dentist.
I authorize Smile Design Center to release my dental and medical information to my insurance company as needed to process claims for services rendered.
I understand and agree that I am financially responsible for all charges not covered by my insurance. I agree to pay all charges at the time services are rendered unless other arrangements have been made in advance.
Smile Design Center may take clinical photographs for treatment planning purposes. I understand these images are part of my medical record.
By signing above, you confirm that you have read and understood the above consent and agree to the terms.
Notice of Privacy Practices — Our Commitment to Your Privacy
Smile Design Center is committed to maintaining the privacy of your personal health information. This notice describes how we may use and disclose your protected health information (PHI) and your rights regarding that information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
Treatment: We may use your PHI to provide, coordinate, or manage your dental care.
Payment: We may use your PHI to bill and receive payment from you, your insurance company, or other payers.
Operations: We may use your PHI for our internal operations including quality assessment, training, and administrative purposes.
You have the right to: request a copy of your health information, request corrections, request restrictions on use or disclosure, request confidential communications, and file a complaint if you believe your privacy rights have been violated.
For questions about our privacy practices, contact us at:
Henderson: 10120 S. Eastern Ave, Suite 375 | (702) 361-9611
Ft. Apache: 6115 S. Fort Apache Rd, Suite 108 | (702) 309-9611
By signing above, you acknowledge that you have received and reviewed this Notice of Privacy Practices.
Please review all sections before submitting. Your forms will be sent securely to our office at sdcoffices@gmail.com.