Getting To Know You As Our Patient Form

GETTING TO KNOW YOU AS OUR PATIENT

Date

PATIENT NAME

SOCIAL SECURITY NUMBER

HOME PHONE

(

)

Home Address

City, State, Zip

Birthdate

/

/

Marital Status

Single

Married

Divorced

Separated

M

F

Drivers License and State

Primary Insurance Company

Group

Subscriber

Secondary Insurance Company

Group

Subscriber

Responsible Party

NAME

SOCIAL SECURITY NUMBER

HOME PHONE

(

)

Home Address

City, State, Zip

Birthdate

/

/

Marital Status

Single

Married

Divorced

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)

Who selected this Office?

Self

Spouse

Parent

Employer

Where did you find the Phone Number to this Office?

Referred by a friend

Yellow Pages

Relative

Insurance Plan

Welcome Wagon

Other

TV/Radio Ad

Newspaper Ad

Direct Mailing

Sign by Building

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

decide 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 case. The financial responsibility 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 arrangements,

must be paid for at the time the 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 releases of any information needed and also authorize my insurance company 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

assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions and agree to their content.

Signed

Date

There may be a charge for any missed appointments or appointments not cancelled 48 hours before the appointment time.