BlissDental
  • Dental Services
    • All-on-4 Dental Implants
    • Botox
    • Dental Checkup
    • Dental Crowns and Dental Bridges
    • Dental Implants
    • Dental Restorations
    • Dental Veneers and Dental Laminates
    • Dentures and Partial Dentures
    • Emergency Dentist
    • Full Mouth Reconstruction
    • Invisalign® Dentist
    • Juvéderm
    • Laser Dentistry
    • Kid Friendly Dentist
    • Pediatric Dental
    • Root Canal Treatment
    • Sedation Dentist
    • Smile Makeover
    • Tooth Fillings
    • Teeth Whitening
    • Tooth Extraction
    • Zoom Teeth Whitening
  • Photo Gallery
  • Videos
  • Testimonials
  • About Us
  • Specials
BlissDental
Contact Us
Call us

(305) 274-6500

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EMAIL
  • Dental Services
    • All-on-4 Dental Implants
    • Botox
    • Dental Checkup
    • Dental Crowns and Dental Bridges
    • Dental Implants
    • Dental Restorations
    • Dental Veneers and Dental Laminates
    • Dentures and Partial Dentures
    • Emergency Dentist
    • Full Mouth Reconstruction
    • Invisalign® Dentist
    • Juvéderm
    • Laser Dentistry
    • Kid Friendly Dentist
    • Pediatric Dental
    • Root Canal Treatment
    • Sedation Dentist
    • Smile Makeover
    • Tooth Fillings
    • Teeth Whitening
    • Tooth Extraction
    • Zoom Teeth Whitening
  • Photo Gallery
  • Videos
  • Testimonials
  • About Us
  • Specials

Dental appointments

1 Patient Registration
2 Covid 19 Questions
3 Dental History Information
4 HIPAA Compliance Patient Consent
5 Payment Arragement
  • Patient Registration

  • Date Format: MM slash DD slash YYYY
  •  

    Patient Health History

  • Do you have a history of:
  •  

    Medical Questions

  • Date Format: MM slash DD slash YYYY
  • Covid 19 Questions

  • Date Format: MM slash DD slash YYYY
  • As a safety measure to our staff and other patients, we kindly ask that you answer the following questions:
  • Como medida de seguridad para nuestro personal y otros pacientes, le rogamos que responda las siguientes preguntas:
  •  

    Gracias por su cooperacion.

     

  • Dental History Information

  • For woman only
  • Date Format: MM slash DD slash YYYY
  • NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.


  •  
  • On a scale from 1 to 10, with 10 being the highest
  • I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

    Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

  • Date Format: MM slash DD slash YYYY
  • HIPAA Compliance Patient Consent

  • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

    You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

    By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

    By signing this form, I understand that:

    • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
    • The practice reserves the right to change the privacy policy as allowed by law.
    • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
    • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
    • The practice may condition receipt of treatment upon execution of this consent.


  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Payment Arragement

  • Payment Agreement

    I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee of $50.00 for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney's fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • I acknowledge having received a copy of the Practice's Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

  • Date Format: MM slash DD slash YYYY
  • (To be signed even if Patient is also the Responsible Party)

  • This field is for validation purposes and should be left unchanged.

Location

8501 SW 124th Ave Ste 104
Kendall, FL 33183
Phone: (305) 274-6500

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5 stars from 259 reviews

Hours of Operation

Monday: 9:00AM to 5:00PM
Tuesday: 9:00AM to 7:00PM
Wednesday: 9:00AM to 5:00PM
Thursday: 8:00AM to 5:00PM
Friday: 9:00AM to 5:00PM
Saturday: 8:00AM to 2:00PM
Sunday: Closed

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