Patient Information

Please take a moment to enter or update your information to help us ensure the quality of you care is excellent. Be sure to click through all pages, even ones that do not apply, and hit submit on last page. Signatures will be taken in the office.

First Name

Middle Initials

Last Name

Preferred Name

Title

Email Address

Home Phone

Work Phone

Work Ext

Mobile Phone

Best Time to Call

Address Line 1

Address Line 2

City

State

Zip Code

Gender
Male
Female
Family Status
Single
Married
Child
Other
Birthday

Previous Visit

Preferred appointment times:
Mon
Tue
Wed
Thur
Fri
Sat
Morning
Afternoon
Evening
Any time
Whom may we thank for referring you to our practice?
Dental Office
Yellow Pages
Internet
Newspaper
School
Work
Other (name below):

Name of person, office, or other source referring you to our practice:

Spouse or Responsible Party Information

Is the responsible party yourself? Use same info from previous pages
Yes
No
The following is for:
The patient’s spouse
The person responsible for payment
Neither – not applicable
First Name

Middle Initials

Last Name

Preferred Name

Title

Email Address

Home Phone

Work Phone

Work Ext

Mobile Phone

Best Time to Call

Address Line 1

Address Line 2

City

State

Zip Code

Gender
Male
Female
Family Status
Single
Married
Child
Other
Birthday

Primary Insurance Information

Primary Dental Insurance:

Insured Information

Insurance ID or SSN #

First Name

Middle Initials

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Insured Birthday

Employer Information

Name

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Plan

Plan Name

ID#/SSN

Group #

Address Line 1

Address Line 2

City

State

Zip Code

Patient’s relationship to insured:
Self
Spouse
Child
Other
Insurance contact phone number ( do include one as first digit)

Primary Medical Insurance:

First Name

Middle Initials

Last Name

Plan Name

Patient’s relationship to insured:
Self
Spouse
Child
Other

Patient Information

Secondary Insurance Information

Secondary Dental Insurance:

Insured Information

First Name

Middle Initials

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Insured Birthday

Employer Information

Name

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Plan

Plan Name

ID #

Group #

Address Line 1

Address Line 2

City

State

Zip Code

Patient’s relationship to insured:
Self
Spouse
Child
Other

Secondary Medical Insurance:

First Name

Middle Initials

Last Name

Plan Name

Patient’s relationship to insured:
Self
Spouse
Child
Other

Truth in Lending

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services and any dental services performed without previous financial arrangements must be paid for in cash at the time services are rendered.

Patients who carry dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms and assist in making collections from insurance companies, and will credit any collections from insurance to the patient’s account. This dental office cannot render services on the assumption that the resulting charges will be covered by insurance.

A service charge of 1.5 % per month and late fee will be charged on the unpaid balance, all accounts with a balance exceeding 60 days, unless previously written financial arrangements are agreed upon.

I understand that the fee estimates for dental care can only be extended for a period of six months from the date of consultation.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Consent for Services

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

I have read the above conditions of treatment and payment and agree to their content.
Signature of patient, parent, or guardian (responsible party):

Relationship to Patient:


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