Date: __________________________
GETTING TO KNOW YOU AS OUR PATIENT
Patient Name
Social Security Number
Home Phone
(
)
Home Address
City, State, Zip
Cell Phone
Email Address
Work Phone
☐ Single
☐ Divorced
☐ MALE
Birthdate
Drivers License and State
Marital Status
☐ Married
☐ Separated
☐ FEMALE
Primary Insurance Company _______________________________________ Group_____________________________________Subscriber________________________
Seconday Insurance Company_______________________________________Group_____________________________________Subscriber________________________
Responsible Party
Name
Social Security Number
Home Phone
(
)
Home Address
City, State, Zip
Birthdate
/
/
Martial Status ☐ Single ☐ Divorced ☐ Married
☐ Separated
Relationship to Patient
Drivers License and State
Responsible Person’s Employer
Occupation
Work Phone
(
)
Business Address
City
State
Zip
Spouse’s Name
Social Security Number
Birthdate
/
/
Spouse’s Employer
Spouse’s Occupation
Spouse’s Work Phone
(
)
Spouse’s Business Address
City
State
Zip
How did you hear about our Office?
(check only one)
☐ Self
☐ Spouse
☐ Parent
☐ Employer
Who selected this office?
Where did you find the Phone Number to this Office? _______________________________________________________________________________________________
☐ Referred by a friend
☐ Postcard or Letter
☐ On-line (directory or advertisement)
☐ Insurance Plan
☐ Health Fair/Community Event
☐ Other ___________
☐ TV/Radio Ad
☐ Newspaper/Magazine ad
☐ Discount Mailer (i.e., Valpak) ☐ Drive by/Signage
If you were referred, whom may we thank for referring you? __________________________________________________________________________
CONSENT
*I will answer all health questions to the best of my knowledge. _____________________________
(Initial)
After explanation by the doctor, I hereby authorize the performance of dental services upon the above named patients and whatever procedures that the judgement of the
doctor may dictate in order to carry out these procedures. I also authorize and request the administration of any anesthetics and x-rays as may be deemed necessary and
advisable by the doctor.
___________________________________________________________
_____________________________________________________________
*Signature
Date
Relationship to Patient
Terms and Conditions
This office depends upon reimbursement from the patient for the costs incurred in their care. The financial rseponsibility of each patient must be determined before treatment.
As a condition of treatment by this office, I understand financial arrangements must be made in advance. All emergency dental services, or any dental service performed without prior financial arrangement, must be paid for at the
time services are performed.
I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment. 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 release of any information needed and also authorize my insurance comapny to pay directly to this office benefits accruing to me under my policy.
I understand that the fee estimate listed for this dental care can only be extended for a period of 90 days from the date of the patient’s examination. I also understand that in order to collect my debt, my credit history may be checked
through the use of my Social Security Number or any other information I have given you. I 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 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 the conditions and agree to their content.
Signed _________________________________________________________________________________ Date _____________________________
There may be a charge for any missed appointments or appointments not cancelled 24 hours befote the appointment time.
GETTING TO KNOW YOU AS OUR PATIENT