Patient Registration Form

Are you allergic to any of the following?

Do you have or have ever had

GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Keith W. Kelley DDS to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make athorough diagnosis of the undersigned patient’s dental condition and needs. I authorize Keith W. Kelley, DDS to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Keith W.Kelley,DDS choose and employ such assistance as deemed necessary. I understand that the use of anesthetic agents embodies certain risks and consent to their use as deemed appropriate by Keith W.Kelley, DDS. To the best of my knowledge, the questions on this form have been accurately answered. I understant that providing incorrect or incomplete information can be dangerous to my/the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status.

FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. this office will not bill a non-costodial parent. I understand that I am responsible for any portion of fees for service rendered not covered by my dental or medical insurance(if any). I further consent to and agree to pay a 7% annual finance charge that will be applied to any balance over 30 days; returned checks will incur a $25.00 fee. I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Keith W.Kelley, DDS and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits payable to him, and to handle any necessary claim appeal(s) on my behalf.