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Fax

859-291-0048

Office Location

340 Fairfield Ave, Bellvue, KY 41073

New Patient Registration Form

New Patient Registration
Dr. Kevin S. Wall
340 Fairfield Avenue
Bellevue, KY 41073
Phone:859-291-7621
Fax: 859-0048
Email: admin@kevinwalldmd.com

New Patient Form

Patient Information


Responsible Party


Dental Insurance Information


Financial Options and Payment Agreements

Taking care of you and your family is our highest priority. That is why, when it comes to talking about finances, our goal is to provide you with clear information regarding our dental fees and your payment options. Please check the preferred payment plan for your family:

PLAN A: I do not plan to use dental insurance, and will be paying out of pocket.

PLAN B: I am interested or already a member of your Dental Savings Plan!

PLAN C: 6 month payment plan using a major credit card (MasterCard or Visa)

PLAN D: Care Credit is a 12 month, same-as-cash option, and our staff would be happy to assist you with the application process.

PLAN E: We will gladly bill your insurance plan, with your understanding that you will be responsible for the amount not covered.
I,
have chosen
above and accept full responsibility for this account. I understand that I am responsible for understanding my insurance benefits, if applicable. I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance. I understand that any insurance estimate given is not a guarantee of actual insurance payment or coverage. I also understand that I am responsible for all charges incurred for dentistry performed upon me and my dependents. Any insurance claim not paid in full after 60 days will become my responsibility at that time. In addition, I also agree to pay for all costs of collection, including attorney fees, and court costs, should additional means of collection be required.

Authorization and Release Agreement

In regards to my medical history, I certify that I have read and understand all of the information provided to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information, or not providing information, can be dangerous to my health.

HIPPA

X-Ray and Records Release

X-Ray Release Form
Dr. Kevin S. Wall
340 Fairfield Avenue
Bellevue, KY 41073
Phone:859-291-7621
Fax: 859-0048
Email: admin@kevinwalldmd.com

Records Release Form for Requested Documents and X-Rays

Medical History Form

Medical History
Dr. Kevin S. Wall
340 Fairfield Avenue
Bellevue, KY 41073
Phone:859-291-7621
Fax: 859-0048
Email: admin@kevinwalldmd.com

Medical History


Do You Have or Have You Had Any of the Following?


Are You Allergic or Have You Had Any Reaction to the Following?


For Women Only


Dental History

Customer Testimonials

Dr. Wall is the best! The receptionist and dental hygienist are top notch! They are all friendly, professional and make your visit easy. Cleaning my teeth was painless and thorough. I live over 40 miles away but happily travel it every 6 months. Thank you Bellevue Family Denistry! 

Janet Fay

From their awesome Meredith who schedules everything and deals with insurance to their friendly and sharp hygienists, Bellevue Family Dentistry is always a great experience. Dr. Wall is an expert who is gifted at his profession and as friendly as you’ll ever find. 
Steve Oldfield

Excellent customer service the entire staff is polite courteous and professional always on time and a very friendly atmosphere.
 
 
Jane Hasenstab

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Contact Information


Patient Information


Appointment Preferences

OFFICE HOURS
Monday - Closed
Tuesday 8:00 AM - 5:00 PM
Wednesday 8:00 AM - 5:00 PM
Thursday 9:00 AM - 5:00 PM
Friday 8:00 AM - 5:00 PM
Saturday - Closed
Sunday - Closed

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