New Patient Info

Click the button below to fill out New Patient Forms online.

**For your convenience and to minimize your wait time in our office, we ask that you complete the New Patient Forms online at least one day before your appointment. There is a 30-minute time limit for completing the paperwork online. If you get an error message, the process did not work. You may try again or print out the forms.**

The information we gather helps us to determine the course of your treatment. We have to know about allergies, sensitivity to anesthetics, long-term medications, etc.

If you’re unable to complete the forms online, you can access them for download at the bottom of this page.

New Patient Forms

Welcome to Southlake Family Dentistry

Thank you for entrusting us with your dental care needs. Our goal is to provide you with the quality care in a friendly, comfortable atmosphere and in the most timely manner possible. This information is designed to guide you through the rapidly changing worlds of medicine and insurance plans. Please read carefully and sign at the bottom of the page indicating your understanding of our policies and procedures.

General Office Rules

We believe your time is as valuable as ours. We do not overbook patients except in cases of emergency and we do our best to stay on schedule to avoid any delays to you. Please assist us in our efforts to stay on time in the following ways. Please arrive on time for your appointment. If you are more than 15 minutes late it may be necessary to reschedule your appointment for a later time.

If you are a new patient, please arrive 15 minutes early to allow for time to fill out necessary medical and insurance information. If paperwork was mailed to you in advance, please bring the completed forms as well as your insurance card and driver’s license to the office on the day of your appointment. Our receptionists are required to keep patient demographic information as up to date as possible. Please understand that we may ask you for any change of address or phone number on subsequent visits. This information helps us to better serve you.

Please realize that it is each individual’s responsibility to keep track of appointments made. If you need to cancel an appointment, please give us 24 hours notice so that we may schedule another patient in the time slot reserved for you. On occasion you may not receive a reminder call, however, please realize it is each individual’s responsibility to keep track of appointments made. If you do not cancel your appointment 24 hours in advance, a $35.00 fee may be charged (except in cases of emergencies or illness) and is payable prior to future visits.

payment for any procedure or portion of a charge not covered by insurance will be collected at the time of your appointment.

It is the ultimate responsibility of the patient to understand his/her insurance coverage. Our staff cannot call your insurance company at the time of your visit to obtain information about your benefits. Insurance policies may change and/or insurance company representatives to not always give us correct or consistent information. In the event of denials, errors, or non-covered services, the patient is responsible for all services rendered. As a courtesy to you, we will file your primary insurance claims. Patients are responsible for their co-payments and/or deductibles at the time services are rendered. If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency or lawyer, you agree to pay any and all of the collections costs, lawyer fees and court cost incurred.

We thank you for understanding our financial policies. This has become necessary in order to continue to accept insurance plans without having patients pay the balance up front and then wait for reimbursement from their insurance company. Our goal is to make your visit with us pleasant and professional. If you have any questions, please feel free to ask our staff for assistance. Thank you again for choosing us for your care.

notice of privacy practices for the office of southlake family dentistry of fort mill, pa 803-548-3342

this notice describes how medical information about you may be used and disclosed and how you can get access to this information. please review it carefully.

Uses and disclosures to carry out treatment, payment, and health care operations

Treatment- This practice may use or disclose your protected health information in consultation between health care providers relating to your treatment or for your referral to another health care provider for your treatment.

Payment- This practice may use or disclose your protected health information for billing, claims management, collection activities, or obtaining payment.

Health care Operation- This practice may use or disclose your protected health information for reviewing the competence or qualifications of health care professionals, or for conducting training programs in which students, trainees, or practitioners participate. This practice may use or disclose your protected health information for accreditation, certification, licensing, or credentialing activities. This practice may use or disclosure your protected health information to our business associates who participate in our healthcare operations. These disclosures will only be made after we have satisfactory assurances in the form of a Business Associates Agreement from the business associate. These assurances will include their agreement to comply with the HIPAA rules and the compliance of any subcontractor with which they do business.

Authorized Uses or Disclosures
Patient rights under HIPAA
Confidential communication requirements
Amendment of protected health information
Right of Breach Notification

An individual has the right to and will receive a notification of any breach of their unsecured protected health information as defined by the Breach Notification Rule. We will fulfill our obligation to provide notice in accordance to HIPAA standards.

Copy of this notice

You have a right to a copy of this notice. Even if you agreed to receive an electronic copy, you may request and receive a paper copy.

Our Duties
Complaints

If at any time you feel we have violated your HIPAA rights, please contact our Privacy Officer or the Secretary of Health and Human Services. This practice will not retaliate against any individual for filing a complaint.

Contact

You have the right to file a complaint with our Privacy Officer at the address and phone number at the top of this notice, or with the Office of Civil Rights, US Department of Health and Human Services, 61 Forsyth St., SW, Suite 3B70, Atlanta, GA 30323.

Effective Date of the Notice is 10-01-13.

Consent for Internet Communications

The following information applies to your giving consent for Internet communication. You will be asked to sign this form during your first visit to our office.

I grant my permission to Southlake Family Dentistry to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice website with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make sure of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the website on my behalf.

i understand the dental practice cannot and does not assume any responsibility for my use or misuse of patient information or other information transmitted, monitored, stored, uploaded or received using the site or the services.

I have read the information above regarding the secured uploading of patient information to the website for the dental practice, and grant the dental practice permission to securely upload my patient information to the website.

Downloadable Forms

If you’re not able to fill the forms out online, we’ve included them below. Click on the links to download and print out these forms at home, where you can fill them out at your leisure and bring them with you to your first visit.