Patient Information Form

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(Please Print)
Date______________________
PATIENT INFORMATION
Name ____________________________________________ Preferred Name _________________
Male
Female
Last
First
M
Address ______________________________________________________
Birth Date ____/____/________
City _________________________ State ______ Zip Code ___________
Present Age ________________
Home Phone # ______________________Work # _____________________ Ext. _______ Cell # _________________
Social Security # ________-________-________
Driver’s License # ________________ State Issued ______
Married
Single
Minor
Divorced
Separated
E-mail _________________________________________
Place of Employment _____________________________ Address ________________________________________
If Full Time College Student - School Name, City, State __________________________________________________
HOW WERE YOU REFERED TO OUR OFFICE? ___________________________________________________
Please check one:
Self
Father
Mother
PERSON RESPONSIBLE FOR ACCOUNT
Name of Person Responsible _______________________________
Wife
Husband
Guardian
* Must include information to process dental claims
DENTAL INSURANCE INFORMATION
Primary Insurance
Secondary Insurance
*Name of Insured Party
*Relationship
*Name of Insured Party
*Relationship
Home Street Address
Home Street Address
City
State
Zip
City
State
Zip
*Social Security Number
*Birth Date
*Social Security Number
*Birth Date
Home Phone
*Work Phone
Home Phone
*Work Phone
*Employer
*Group #
*Employer
*Group #
*Dental Insurance Company
*Dental Insurance Company
*Address for Mailing Claims
*Address for Mailing Claims
*City
* State
*Zip
City
*State
*Zip
*Insurance Phone Number
*Insurance Phone Number
METHOD OF PAYMENT
I do not have dental insurance and I agree to pay for any and all treatment IN FULL on the day of service.
I have dental insurance and am responsible for paying my estimated portion on the day services are rendered. I am
responsible for calling my insurance company if I have any questions about claims or benefits.
AUTHORIZATION ALL PATIENTS OR GUARDIANS MUST SIGN
I authorize the dentist to perform diagnostic procedures and treatment, including administration of medicine, local and general
anesthetics, and extractions along with other surgical and dental procedures that may be necessary for proper dental care.
I authorize the use of a third party company to verify my employer’s insurance company and insurance plan.
I agree that I am responsible for paying my balance on the day services are rendered.
I am responsible for all legal and business costs related to non-payment of accounts including collection costs.
X_______________________________________________________
__________________________
Patients or Guardian’s Signature
Date

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