New Patient Form – Portland

Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
  • Patient Information

  • Emergency Contact

    This should be the nearest relative who does not live with the patient.
  • Insurance Information

  • Primary Insurance

  • Secondary Insurance

  • Authorization

    All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Columbia River Dentistry to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to Columbia River Dentistry. I permit a copy of this authorization to be used in place of the original. I give Columbia River Dentistry, its employees, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.
  • Consent for Treatment

    I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient.
    Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care.
    I agree to the use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
    I have read, understood, and agree to the above treatment policy.
  • Payment Method

    Notice: Payment is due at the time of service unless alternative arrangements have been made in advance.
    Start treatment immediately and pay over time with low monthly payments.
  • Payment Policies

    Thank you for taking the time to understand our payment policies. For any questions about fees, financial policies, or your responsibilities, please ask one of our office staff for clarification.
  • For Patients with Dental Insurance

    We accept dental insurance assignments, with the understanding that any uninsured portion not covered by your insurance plan is to be paid by you at the time of service. As a courtesy, our office will file all applicable insurance forms. Please note that although we strive to provide accurate information, such information is not a guarantee of payment or eligibility with your insurance company and is only an estimate. Your dental insurance plan is a contract between you, your employer, and the insurance company. Depending on your specific insurance plan, your dental insurance may not fully cover our office dental fees for the services we render. The difference between our office dental fees and your insurance reimbursement is your responsibility.
  • Returned Checks

    Personal checks that are returned due to "insufficient funds" are subject to a $25.00 service fee.
  • Service Charge

    Payment is due at each appointment. I agree to pay any outstanding insurance balance within 60 days. If I do not pay the entire new balance within 60 days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1.5% per month (or a minimum charge of $2.50 for a minimum balance of $25.00) which is an annual percentage rate of 18% applied to the last month's balance. In case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account balance or any future accounts. Please be advised that there is a $50.00 fee charged for missed or broken appointments without 24 hours notice. To avoid this charge, kindly give us a minimum of 24 hours notice for any appointment cancellation. Feel free to contact us at any time with questions you may have.
  • X-Ray/Records Release

    There is a fee of $25.00 for any release of X-rays and/or records.
  • Minors

    Adult patients are responsible for full payment at time of service. The adult accompanying a minor is responsible for payment. This office will not bill a non-custodial parent for services delivered to a minor. For unaccompanied minors, treatment may be denied unless charges have been pre-approved to a credit card or other payment arrangements have been made
  • Authorization

    I hereby authorize payment directly to Columbia River Dentistry of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of the above-named patient's dental treatment. The information on the page and the dental/medical histories are correct to the best of my knowledge. I grant the right to Columbia River Dentistry to release the patient's dental and/or medical histories and other information about the patient's dental treatment to third-party payers and/or other health professionals.
  • Dental History

  • Previous Dentist

  • Today's Visit

  • Dental Concerns

    Check all that apply.
  • Have you ever had:

    Check all that apply.
  • Ratings

  • Medical History

  • Have you ever had:

    Check all that apply.
  • Have you ever had an adverse reaction or allergies to any medication or substance?

    Check all that apply.
  • All of the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.