Patient Information Form With Emergency Contact And Health Information (Page 2 of 2) in pdf

If Applicable-Responsible Party Information- (Guardian or Parent of Minor Child)

Name: _______________________________________________ Relationship to Patient: __________________________

Male

Female

Social Security #: ________________________________ Birth Date:

Phone (Home): ________________ (Work): ________________ Ext: ______ (Cell)

Address:

Street

Apartment #

City

State

Zip Code

Dental Insurance Information

Primary

Insurance Plan Name:

Phone #:

Claims Mailing Address:

Name of Insured: _______________________________________________ Millitary Rank: _________________

Last

First

Insured's Birth Date: _________________ ID #: _____________________ Group #:

Insured's Employer Name:

Phone #:

Patient's relationship to insured:

Self

Spouse

Child

Other ___________________

Secondary

Insurance Plan Name:

Phone #:

Claims Mailing Address:

Name of Insured: _______________________________________________ Millitary Rank: ________________

Last

First

Insured's Birth Date: _________________ ID #: _____________________ Group #:

Insured's Employer Name:

Phone #:

Patient's relationship to insured:

Self

Spouse

Child

Other ___________________

Consent for Services

Appointment Guidelines

- I understand that Bridgeport Dental Arts (BDA) requires 2 business days notice in order to reschedule any appointments; failure to give

sufficient notice could result in a cancellation fee of $50 per hour scheduled. ________initial

Payment

- I agree to pay at the time services are rendered and understand that the forms of payment are Cash, Check, Visa, Master Card, Discover & Care Credit. In the case

that my insurance company does not pay the estimated amount I understand that BDA will send me a statement of my balance. I agree to pay all balances bill to me by the due

date and if I need to make financial arrangements I will contact the office prior to my due date. I also understand the I am subject to a 12% APR finance charge on any balances

not paid with a minimum charge of $2.00 per month Failing to comply by the due date could result in my account being forward to a third party for collections which could damage

my credit. I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. ________initial

Insurance-

I understand that all dental services furnished are charged directly to me, the patient or guardian and that I am personally responsible for payment of all dental

services. BDA will help prepare the insurance forms or assist in making collections from insurance companies and will credit any such collections to my account. However, this

dental office cannot render services on the assumption that our charges will be paid by an insurance company. I also acknowledge that it is my responsibility to know and

understand my insurance benefits, and that the estimated copayments given are just estimates. Should I require a definite answer, I will contact my insurance

company directly. ________initial

HIPAA

I grant permission to BDA to contact me at home or at my work to discuss matters related to this form. I understand that this office complies with the Healthcare

Information Privacy Practices Act (HIPAA). A full explanation is available for me, at the front desk, should I require more information. ________initial

Treatment

-I understand that any treatment diagnosed will be explained to me and I will be given the choice to complete the recommended treatment. I will not hold BDA

responsible for any adverse conditions that may result from not completing the recommended treatment. Furthermore I understand that regular maintenance is always

recommended should I fail to keep up with the regular maintenance schedule set forth the restorative treatment i.e. fillings, crowns etc. could fail prematurely. ________initial

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my

health, I will inform the doctors at the next appointment without fail

____________________________________________________

_______________________

Signature of patient, parent or guardian

Date

Relationship to Patient

____________________________________________________

_______________________

Signature of guarantor of payment/responsible party

Date

Relationship to Patient