Patient Information Form printable pdf download

PATIENT INFORMATION

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(This information is necessary for our files and will be considered CONFIDENTIAL)

Patient’s Name: ___________________________________________________________ Male

Female

Date_____________

If patient is a minor, state name of legal guardian: _______________________________________________ Relationship: ________

Address: ________________________________________________________________________________ For how long: _______

Home Telephone: ______________________ Cell Number: ________________________ Email Address: _____________________

Patient is: Minor

Single

Married

Divorced

Separated

Widowed

Birth Date: ________________________

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Employed By: ____________________________________________________________________________ How long? _________

Address: ____________________________________________________________________________________________________

Phone Number: ____________________________ Ext: ______________ Occupation: _____________________________________

Name of Physician: _________________________________________________________ Phone Number: ____________________

Former Dentist: ____________________________________________________________ Phone Number: ____________________

Why are you changing dentist? ________________________ Students, name of school/college & city: _________________________

Whom may we Thank for Referring you?

Insurance

Website

Other _______________

Friend/Relative ________________

FINANCIAL & INSURANCE INFORMATION

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Person responsible for this account: _________________________________________________ Relationship: ________________

Address (if different than above): ________________________________________________________________________________

Home Telephone: __________________________ Cell Number: ________________________ Work Number: __________________

Name of Primary Insurance Company: ______________________________ Telephone Number: __________________________

Insured Person: ____________________________________________ Relationship: ____________ Date of Birth: ______________

Social Security

Member ID: ______________________________ Name of Employer: __________________________________

Name of Secondary Insurance Company: ____________________________ Telephone Number: __________________________

Insured Person: _____________________________________________ Relationship: ____________ Date of Birth: _____________

Social Security

Member ID: _______________________________ Name of Employer: _________________________________

TERMS & CONDITIONS

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As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients

for the cost incurred in their care and financial responsibility on the part of each patient must be determined before treatment. I understand that dental services furnished

to me are charged directly to me and that I am personally responsible for payment of all dental services. If I carry insurance, I understand that this office will help

prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental office cannot

render services on the assumption that charges will be paid by an insurance company. Assignment of Insurance: I hereby authorize my insurance company to pay

directly to my dentist benefits accruing to me under my policy. I understand that the fee estimate listed for this dental case can only be extended for a period of six

months from the date of patient’s examination. In consideration of the professional services rendered to me or at my request, by the Doctor and/or his staff, I agree to

pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of

said services shall be billed unless objected to by me, in writing, within the time for payment thereof. Additionally, I agree that a waiver for any breach of any term or

condition hereunder shall not constitute a waiver of any further term or condition. I further agree that in the event that either this office or I institute any legal

proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred, including

reasonable attorney’s and/or collection fees. I grant my permission to you, or your assigns, 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 agree to their content:

Signed: _________________________________________________________________ Date:_____________________________