Thank you for selecting our dental healthcare team! We
will strive to provide you with the best possible dental care. To
help us meet all your dental healthcare needs, please fill out this form
completely in ink. Don't forget to bring it with you
when you visit or office. If you have any questions or need assistance,
please ask us - we will be happy to help.
1. Personal Information
Date _______________________________________________________________________________________
Birthdate ____________________________________________________________________________________
Soc. Sec.# ___________________________________________________________________________________
Name _______________________________________________________________________________________
Wishes to be called _____________________________________________________________________________
Male____ Female____ Minor____ Single____ Married___ Divorced____ Widowed____ Separated____
Address _____________________________________________________________________________________
City, State, Zip ________________________________________________________________________________
Employer______________________________ Occupation _____________________________________________
Referred by ___________________________________________________________________________________
2. Responsible Party
Who is responsible for the account?
Name ________________________________________________________________________________________
Relationship to patient ___________________________________________________________________________
Birthdate _____________________________ Driver’s License # _________________________________________
Soc. Sec. # ____________________________ Work Phone _____________________ Ext.# ____________________
Car Phone ____________________________________________________________________________________
Where do you prefer to receive calls? Home ________ Work _________ Car __________
When is the best time to reach you? Time __________ Days _______________________
In the event of an emergency, who should we contact?
Address ______________________________________________________________________________________
City, State, Zip ________________________________________________________________________________
Employer _____________________________________________________________________________________
Occupation ___________________________________________________________________________________
Work Phone _____________________________ Ext.# ________________________________________________
Home Phone __________________________________________________________________________________
3. Telephone
Home Phone __________________________________________________________________________________
Name _____________________Relationship_______________Work#___________Home#____________________
4. Dental Insurance Information
Primary Insurance__________________Additional Insurance__________________
Name of Insured__________________________ Name of Insured____________________________
Relationship to patient______________________ Relationship to patient_______________________
Insider’s birthdate_________________________ Insured’s birthdate _________________________
Soc. Sec. # _______________________________ Soc. Sec. # ________________________________
Employer ________________________________ Employer _________________________________
Date Employed ____________________________ Date Employed ____________________________
Occupation _______________________________ Occupation _______________________________
Insurance Company _________________________ Insurance Company _________________________
Group # __________________________________ Group # __________________________________
Employee/Cert. # ___________________________ Employee/Cert. # ___________________________
Ins. Co. Address ___________________________ Ins. Co. Address ___________________________
Deductible ________________________________ Deductible ________________________________
Amount already used ________________________ Amount already used _______________________
Max. annual benefit _________________________ Max. annual benefit _________________________
5. Authorization and Release
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or other health practitioners.
I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.
I understand that my dental insurance carrier may pay less than the actual bill services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
X____________________________________________________________________________________________
Signature of patient or parent if minor Date
6. Financial Arrangements
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
_____ Cash
_____ Personal Check
_____ Credit Card _____ Visa _____ MC
_____ I wish to discuss the dental office’s policy.
Late Charges
If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.
Thank you for filling out this form completely. The information you have provided will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask - we are always happy to help.