Patient Information Form printable pdf download

PATIENT INFORMATION

Dental Office of Whitney R. Johnson, D.D.S.

Patient’s Full Name: _________________________________________________________________

Mrs. Ms Miss Mr. Dr Prof

Preferred Name: ____________________________________________

Birth Date: ______________________________

Social Security Number: ______________________________________ Patient’s Email ______________________________

Patient’s Cell Phone: ___________________________________ Patient’s Work Phone: __________________________Ext:__________

Patient’s Home Phone___________________________________

Patient’s Street Address: _______________________________________Address 2: _______________________________________

City_____________________

State_________

Zip____________

Student Status if Dependant Over 19 (for insurance) ____Nonstudent

_____Fulltime

___Parttime

__________________________________________

College Name

RESPONSIBLE PARTY’S INFORMATION

Responsible Party’s Name ___________________________________________________________ Relationship_____________________

Responsible Party’s Address _________________________________________________________

City _________________________________________ State _________________ Zip ______________________

Responsible Party’s Home Phone _____________________________ Responsible Party’s Work Phone____________________________

Responsible Party’s Date of Birth _________________________Responsible Party’s Social Security Number ______________________

DENTAL INSURACE INFORMATION

Name Of Dental Insurance Company _________________________________________________________________________________

Address Of Dental Insurance Company________________________________________________________________________________

Name Of Insured________________________________________ Social Security Number of Insured_____________________________

Insured’s Group Number______________________________ Name of Employer_____________________________________________

Name of Secondary Dental Insurance_________________________________________________________________________________

Address of Secondary Dental Insurance Company_______________________________________________________________________

Name of Secondary Insured________________________________Soc. Sec. Number Of Second Insured_________________________

Secondary Insured’s Group Number_____________________Name Of Secondary Employer___________________________________

FINANCIAL AGREEMENT

I acknowledge that payment is due at the time of treatment, unless other arrangements are made prior to dental

treatment. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a

minor/child. I accept full financial responsibility for all charges not covered by insurance.

MINOR/CHILD CONSENT

I, being the parent or guardian of__________________________________ do hereby request and authorize the

dental staff to perform necessary dental services for my child, including but not limited to X-rays, and

administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual

appointment when the treatment is rendered.

AUTHORIZATION

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I

understand that I am responsible for all costs of treatment. I hereby authorize the Dental Office to administer such

medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The

information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to

the dentist to release my dental/medical histories and other information about my dental treatment to third party

payors and/or other health professionals.

X_____________________________________________________Date________________________________

Adult Patient __ Father(or Husband) __ Mother(or wife) __Guardian

PATIENT INFORMATION

Patient Information Form

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