New Patient Forms

Your First VisitNew Patient Forms

At your first visit, we will ask you to fill out our New Patient Forms so that we can obtain all pertinent information to allow us to provide you with the highest quality service.

If you’re a new patient, you can either complete your registration forms at home or at our office when you come in for your first visit.

If you’d like to save some time and fill them out at home, simply download the four forms below, fill them out and bring them with you to your appointment. You can also fax your forms to us at 303-666-5906 (Lafayette).

  1. Health History (signature required)
  2. HIPPA (read only)
  3. HIPPA Form (signature required)
  4. Financial Policy (signature required)

If you’re already an existing Sage Dental patient, there’s no need to complete these forms again.

About the Forms

Health History Form

On our confidential Health History form, we will gather the information we need to better serve you, including:

  • Relevant medical history
  • Medications you might be taking
  • Dental insurance coverage you may have

Notice of Privacy Practices (HIPPA* Form)

The Department of Health and Human Services has established a “Privacy Rule” to help insure the personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient’s consent for uses and disclosures of health information about the patient, to carry out treatment, payment, or health care operations. As our patient, we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy.  So take a moment to read it and then sign the signature form.

* HIPPA is an acronym for Health Insurance Portability and Accountability Act

Financial Policy Form

This form simply confirms that you will provide for payment at time of service and that the the exact amount your insurance will cover cannot be guaranteed at the time of your appointment.

It also outlines that Sage Dental has a 24 hour cancellation / rescheduling policy. If you miss your appointment, cancel or change your appointment with less than 24 hours notice, you will be charged $50. This policy is in place out of respect for our staff as well as our clients. Cancellations with less than 24 hours notice are difficult to fill. By giving last minute notice or no notice at all, you prevent another patient from being able to schedule into that time slot.

X-Rays

If you’ve had dental x-rays in the last six months, please bring them to your first appointment.
If you have any questions about how to complete the forms, please call our office and we can assist you. (303) 604-6355