Home - Pospisil Family Dentistry

Patient Forms 480-838-3315 Tempe

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Our Services

Cleanings & Prevention

Cleaning & Prevention are the foundation of any plan for a healthy smile.

Cosmetic Dentistry

You want your smile to be attractive as well as healthy!

Periodontal Disease

Periodontal Disease is a serious health issue that requires treatment and ongoing maintenance.

Restorations

We provide a wide range of restorative services!

Dental Emergencies

In case of a dental emergency you can count on us!

Our Office

Testimonials

Contact us today!

APPOINTMENT

New Patient Full - Child r1

Step 1 of 4

My Personal Information
Name*
First Middle Last
Date of Birth*
Phone Number*
Emergency Contact
Name*
Relationship*
Phone Number*
Primary Care Physician
Do you have a primary care physician?*
- Yes
- No
Primary Care Physician Details
Name*
Phone Number*
Preferred Pharmacy/Drugstore
Name
Phone Number
Other Physicians
Physician Info
Click the + icon at right to add rows.
Name Specialty Phone Number
My Allergies
Do you have any allergies?*
- Yes
- No
Please list all allergies:*
My Medical Conditions
Do you have any medical conditions?*
- Yes
- No
Please list all medical conditions:*
Medications
Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
Click the + icon at right to add rows.
Click the + icon at right to add rows.
What I'm taking Form (pill, injection, etc) Dosage Home much and when Use (regularly or occasionally) Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing) Notes, directions, reasons for use
Signature of Patient or Guardian*
Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Signature Date*

Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.

Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

Insured Patients:

As a courtesy, we will process your insurance claims for you. Please understand the following:
1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
6. All charges are your responsibility regardless of any insurance benefits.
All Patients:

Please be aware of the following:
1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
2. The charge for each returned check is $50.00.
Signature of Patient or Guardian*
Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.
Signature Date*
Comments
This field is for validation purposes and should be left unchanged.

New Patient Full - Adult

Step 1 of 4

My Personal Information
Name*
First Middle Last
Date of Birth*
Phone Number*
Emergency Contact
Name*
Relationship*
Phone Number*
Primary Care Physician
Do you have a primary care physician?*
- Yes
- No
Primary Care Physician Details
Name*
Phone Number*
Preferred Pharmacy/Drugstore
Name
Phone Number
Other Physicians
Physician Info
Click the + icon at right to add rows.
Name Specialty Phone Number
My Allergies
Do you have any allergies?*
- Yes
- No
Please list all allergies:*
My Medical Conditions
Do you have any medical conditions?*
- Yes
- No
Please list all medical conditions:*
Medications
Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
Click the + icon at right to add rows.
Click the + icon at right to add rows.
What I'm taking Form (pill, injection, etc) Dosage Home much and when Use (regularly or occasionally) Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing) Notes, directions, reasons for use
Signature of Patient or Guardian*
Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.

Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Signature Date*

Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies.

When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment.

Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved).

Insured Patients:

As a courtesy, we will process your insurance claims for you. Please understand the following:
1. Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract.
2. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure.
3. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees.
4. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only.
5. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement
6. All charges are your responsibility regardless of any insurance benefits.
All Patients:

Please be aware of the following:
1. Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me.
2. The charge for each returned check is $50.00.
Signature of Patient or Guardian*
Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.
Signature Date*
Comments
This field is for validation purposes and should be left unchanged.

Medication & Personal Information

My Personal Information
Name*
First Middle Last
Date of Birth*
Phone Number
Emergency Contact
Name*
Relationship*
Phone Number
Primary Care Physician
Name*
Phone Number
Pharmacy/Drugstore
Name*
Phone Number
Other Physicians
Physician Info
Click the + icon at right to add rows.
Name Specialty Phone Number
My Allergies
Please list all allergies:
My Medical Conditions
Please list all medical conditions:
Medications
Be sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.
Click the + icon at right to add rows.
Click the + icon at right to add rows.
What I'm taking Form (pill, injection, etc) Dosage Home much and when Use (regularly or occasionally) Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing) Notes, directions, reasons for use
Email
This field is for validation purposes and should be left unchanged.

What I'm taking	Form (pill, injection, etc)	Dosage	Home much and when	Use (regularly or occasionally)	Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing)	Notes, directions, reasons for use

Name	Specialty	Phone Number

Name	Specialty	Phone Number

Name	Specialty	Phone Number

Our Services

Cleanings & Prevention

Cosmetic Dentistry

Periodontal Disease

Restorations

Dental Emergencies

Our Office

Testimonials

Testimonial 4

Contact us today!

Our Practice

Patient Info

Testimonials

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