Fillable Confidential Dental And Medical History printable pdf download

Conﬁdential Dental and medical History

Patient’s Name _____________________________________________________ Age_______ Date of Birth ___________________

Address __________________________________________ City, State, Zip______________________________________________

Home Phone ______________________________________________ Cell ______________________________________________

Work Phone ______________________________________________ E-mail _____________________________________________

Best Contact:

Best Time to Reach You: _______________________________________________

Cell

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Home

SS# ___________________________________________________ Marital Status:

SiNgle

marrieD

WiDoWeD

DivorCeD

Employer ________________________________ Employer Address ___________________________________________________

Spouse’s Name __________________________________ Spouse’s Phone: (Work) ____________________ (Cell) _________________

Emergency Contact ________________________________ Relation ____________ Emergency Phone _______________________

Do you have dental insurance?

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If YES, Insurance Carrier’s Name ____________________________________________

Group # _______________________ Phone _______________________ Subscriber’s Name _______________________________

Relation to Patient __________________ Subscriber’s SS# ________________________ Subscriber’s Date of Birth ______________

Employer/Co. Name __________________________________________________ Phone __________________________________

Employer/Co. Address, City, State, Zip _____________________________________________________________________________

Insurance Carrier Address,City,State,Zip ___________________________________________________________________________

HOW DID YOU HEAR ABOUT US ? ______________________________________________________________________________

Would you like to receive appointment reminders via text message?

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Would you like to become friends with Carlson Dental Group on to receive special offers?

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oFFiCe poliCy regarDiNg iNSUraNCe: Your dental insurance is a contract between you, your employer, and the insurance company. We are

not a party to that contract. The responsibility of payment ultimately lies with the patient, not the insurance company. As a courtesy, we will file

your claim on your behalf. I understand that I am required to pay my “Estimated Patient Portion” and any deductible due, to Carlson Dental Group

at the time of my visit. Failure to provide our office with all the information necessary to file your insurance claim will require full payment at the

time of service. Any portion of treatment that the insurance does not cover is the patient’s responsibility. A statement will be sent to the patient for

any balance which is not paid by the insurance company. I hereby authorize the release of any dental information that is needed to file my insurance.

I consent to treatment for myself/family under 18 years old. I have read the above statements and understand that I am responsible for payment in

full after (45) days of my treatment, regardless of any delay in payment(s) by my insurance company. I understand that a 1.5% per month late charge

may be added to my account for any overdue balance that is my responsibility.

_________________________________________________________________________________

T y p e N a m e

D aT e

904.262.8409

Bartram Oﬃce

Riverside Oﬃce

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13241 Bartram Park Blvd.