206-487-7800 • 1515 N. 200TH ST., SHORELINE, WA 98133

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How Did You Hear About Our Office? Fields marked with * are required

Terms And Conditions Fields marked with * are required
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
                   

Release Authorization Fields marked with * are required
I hereby grant permission to Eric S. Yao, DDS, MAGD or any of his staff members to take photographs or videos of my teeth, jaws, and face. I understand that my photographs, slides, videos, and my patient testimonial can be used for educational lectures, marketing and advertising for this dental practice (including Dr. Eric S. Yao's website, Facebook posts, YouTube, magazines/journal, and other social media). I also understand that if my photographs, slides, and videos are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used. I do not expect compensation, financial or otherwise, for the use of these photographs.

I acknowledge Eric S. Yao, DDS, MAGD's right to crop or otherwise treat the photograph at his discretion. I also acknowledge that Dr. Eric S. Yao may choose not to use my photograph and testimonial at this time, but may do so at his own discretion at a later date. I also understand that once my image is posted on Dr. Eric S. Yao's website, Facebook, YouTube, and other social media, the image can be downloaded by any computer user, which is beyond the control of Dr. Eric S. Yao, and I will hold him and any of his affiliated offices harmless from any such use or download.

I hereby freely and voluntarily consent to the use of my photograph and testimonial as stated above until I revoke this consent in writing.
                   
I agree to the above but only agree to have my teeth shown without any identifying features. (Please check one or the other, or none)
                   
I understand that by providing a signature below, I certify that all the information provided is true and correct, and am confirming I have read and understand the Privacy Policy and am providing written instructions to this practice under the FCRA authorizing this practice to obtain information from my personal credit profile from one or more credit reporting agencies. I authorize this practice to obtain such information solely to conduct a prequalification for credit for your health credit assessment.
                   

Form Signature Fields marked with * are required
Date: 11/28/2021

Patient Financial Policy Fields marked with * are required
Please click here to review the details of our Financial Policy Agreement Financial Policies Agreement. I acknowledge that I have received and agree to the Financial Policies Agreement.

  • Payment Options - cash/check, credit cards, care credit, in-house payment plan, and Quality Dental Plan membership program.
  • As a courtesy, we will file your insurance claims for you. Please understand that any expected payment from your insurance is an estimate only.
  • A 50% deposit is due at or before the appointment scheduled for all procedures that require laboratory work. (e.g. crowns, implant crowns, bridges, partial dentures, complete dentures, relines, night guards, etc.)
  • 2 BUSINESS DAYS CHANGE OF APPOINTMENT and NO SHOW policy to avoid a $100 administration fee.
                   
Date: 11/28/2021

HIPAA And Privacy Practices Consent Fields marked with * are required
I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.

I give this practice consent to leave messages with household members and answering machines when necessary.

I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.

I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.

I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).

I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.
                   
Date: 11/28/2021

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