Welcome! Thank you for visiting Murfree Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form.

Please enter the patient's name below:

First Name *

Last Name *

Contact

Please fill out the information below

Preferred Name

Address *

City *

State *

Zip *

Date of Birth *

Social Security #

Email *

Home Phone

Work Phone

Mobile Phone *

Employer

May we contact you at work? Yes
No

Emergency Contact

Name *

Phone *

←

Primary Insurance Carrier

Does the patient have insurance?

Yes No

Insurance Authorization Statement

Yes No

If Patient is Under 18

Is the patient under 18?

Yes No

←

Treatment Authorization Statement

I authorize and give consent to Murfree Dental to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated.
I hereby authorize Dr. Murfree to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care.
I certify to the above statements regarding my medical condition & history to the best of my knowledge
Payment for all treatment and services rendered to Murfree Dental are my responsibility.

PATIENTS SIGNATURE *

Date

PARENT/GUARDIAN SIGNATURE (If patient is a child or requires a guardian)

Date

←

Services

We have a variety of specialty services available. If you would like to hear more about or may be interested in any of the following, please mark the appropriate box.

Sedation Dentistry (Oral Conscious Sedation) Tooth Whitening Cosmetic Veneers/ Lumineers CPAP alternatives with an oral appliance Snoring appliance therapy Dental Implants for missing teeth Denture Stabilization with Dental Implants or mini-implants Cosmetic Orthodontics (straightening of teeth) with Invisalign or 6 Month Smiles TMJ related Pain, Headaches, Migraines therapy

Please note any other Questions or Concerns that you want to make sure we address below:

←

Acknowledgement of Receipt of Notice of Privacy Practices, Consent for Services & Financial Policy

*You May Refuse To Sign This Acknowledgement
I have had a chance to read or have received a copy of this office’s NOTICE OF PRIVACY PRACTICES (standard HIPPA notice).

Initials *

I have had a chance to read or have received a copy of this office’s CONSENT FOR SERVICES & FINANCIAL POLICY.

Initials *

Please Print Name *

Signature *

Date *

For Office Use Only

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:

Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement

Other (Please specify)

←

Broken Appointment Policy

When a dental reservation is made in our office, a specific time is reserved for you to see our dentist or hygienist. The appointment allows the dentist to meet your needs and also schedule other equally important patients. Broken appointments result in a loss of valuable time that could be spent with patients in need of treatment and they are very costly to our office.
We respectfully ask you to give us a minimum of 48 hours’ notice to cancel or reschedule your reservation and we ask you to reschedule recall hygiene visits within 30 days of your recommended recall schedule. If notice is not given we will charge the card provided $50.00 per hour that the patient was scheduled. Please help us serve you better by keeping scheduled appointments.

Signature of patient, parent or guardian: *

Date *

Relationship to Patient: *

Patient Registration Form

Welcome! Thank you for visiting Murfree Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form.

Contact

Employer

Emergency Contact

Primary Insurance Carrier

Insurance Authorization Statement

If Patient is Under 18

Other Information

Conditions

Allergies

Questionnaire

Treatment Authorization Statement

Oral Health Survey

Dental Health Survey

Services

Acknowledgement of Receipt of Notice of Privacy Practices, Consent for Services & Financial Policy

For Office Use Only

Broken Appointment Policy

Day	Hours
Monday	9:00 a.m. - 5:00 p.m.
Tuesday	9:00 a.m. - 6:00 p.m.
Wednesday	Closed
Thursday	9:00 a.m. - 5:00 p.m.
Friday	Closed
Saturday	Closed
Sunday	Closed