212SMILING (212-764-5464) info@212smiling.com

New Patient Form

Please fill out the following online form to speed up the process and not have to fill out the forms in the office. 

Step 1 of 2

  • Patient Information

  • Emergency Contact Information

  • Account / Insurance Information

  • Notices

    Authorization to Pay Benefits to Dentist
    I hereby authorize payment directly to the above dentist for the surgical and or dental benefits, if any, otherwise payable to me for services as described above but not to exceed the benefits provided for covered services.

    Terms and Conditions
    Undersigned hereby authorizes Dr. Yung Kim to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Yung Kim to make a thorough diagnosis of patient’s dental needs and may be used for educational purposes. I also authorize Dr. Yung Kim and Associates to perform any and all forms of treatment, medication and therapy that may be indicated in connection with my conditions and further authorize and consent that Dr. Yung Kim chooses and employs such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand responsibility of payment for dentist services provided in the office for myself or my dependents is mine, due and payable at the time of services I rendered unless financial arrangements have been made. I further understand that in the event of default I promise to pay legal interest on the indebtedness.

    Consent for Services
    As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. We bill Usual and Customary fees. Insurance payments are not guaranteed until received from the insurance company. If we agree to accept assignment, we charge the contractual co pay percentage and at the time of insurance payment make the necessary adjustment. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. In the event that full payment for charges incurred in connection with my dental care is not made, I agree to pay all costs of collection, including reasonable attorneys’ fees, and interest at the rate of twenty-five percent (25%) of the whole balance. I agree to submit myself to the jurisdiction of the courts of the New York, NY. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. Please note not all providers and specialists are in network with all insurances and may not participate with your insurance plan.
    I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.