Form

New Patient Questionnaire

You have expressed interest in establishing your child as a patient of Canandaigua Smiles for dental care under board certified pediatric dentists.
Once we have received your completed form we will make every attempt to contact you within 48 business hours.

We have created this form to simplify our new patient process.

This allows us to focus on what is most important: providing excellent dental care for your family.

Our office "participates" with (also known as preferred provider) the following insurance companies for employer sponsored plans (the insurance is provided through a parent or guardian's employer):

Excellus BCBS
Delta Dental

As a courtesy, we will file claims on your behalf for ANY insurance company that will provide or pay for services out of network. Please check with your insurance supplier for more information on out of network claims.

We also are contracted, or participate with, the following NY State sponsored plans:

Excellus Child Health Plus (through Healthplex)
Excellus Blue Choice Option Medicaid (through Healthplex)

We DO NOT have the ability to bill any other state sponsored plan (even if they are through Healthplex)

This includes NYS Mediciad (NYS Benefit Card only), MVP Child Health Plus or Medicaid, Molina Child Health Plus or Medicaid, YourCare Child Health Plus or Medicaid, United Healthcare Child Health Plus or Medicaid, Fidelis Child Health Plus or Medicaid

Type of Appointment Being Requested

Reason for New Patient Visit (check all that apply)

Other

Name of Referring Office or Provider

Referring Office or Provider Phone Number

Name of Previous Office or Provider

Previous Office or Provider Phone Number

Has your child had dental x-rays

Do you have a copy of a referral?

Copy of Referral (If Available)

Upload or drag files here

Patient

Patient Date Of Birth

First Parent/Guardian listed is the the primary contact.

They will receive ALL communications and confirmation messages.

FIRST PARENT/GUARDIAN

PARENT GUARDIAN Date Of Birth

SSN (required if self-pay)

Phone

Email (for new patient forms and reminders)

Address

City

Zip Code

CHILD LIVES HERE

Please summarize custody agreement, if any

SECOND PARENT/GUARDIAN

SECOND PARENT/GUARDIAN Date Of Birth

SSN

Phone

Address

City

Zip Code

CHILD LIVES HERE

For all patients: Payment is due at time of service.

We accept the following forms of payment:

Credit Card (Visa/MasterCard/Discover/Amex)
Cash
Check*
Care Credit

*Returned checks will be subject to a minimum $25.00 bank fee. We retain the right to refuse checks as payment.

If insurance benefits are available:

Payment of the following is due at time of service

Deductible
Co-Pay
Co-Insurance
Non-Covered Services
Other charges as indicated in advance

Is your child covered under any dental insurance?

If your child is covered by more than one insurance plan, NY State plans such as Child Health Plus and Medicaid are ALWAYS secondary.

Insurance Provider

Insurance Phone Number (for Dentist/Provider)

Address

City

Zip Code

Claims Address is typically on back of ID card

CIN/Member/Subscriber ID#

Policy Holder/ Subscriber SSN (required if ID# not available)

Policy Holder/Subscriber

Date Of Birth

Front of Insurance Card

Upload or drag files here

Back of Insurance Card

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Is your child covered under any additional insurance?

If your child is covered by more than one insurance plan, NY State plans such as Child Health Plus and Medicaid are ALWAYS secondary.

Additional Dental Coverage Insurance Company

Provider/Dental Phone Number

Address

City

Zip Code

Claims Address is typically on back of ID card

Policy Holder/Subscriber

Date Of Birth

Subscriber's Employer

CIN/Member/Subscriber ID#

Policy Holder/ Subscriber SSN (required if ID# not available)

Front of Insurance Card

Upload or drag files here

Back of Insurance Card

Upload or drag files here