Patient Information

First Name

Last Name

Nick Name

Home Phone

Work Phone

Cell Phone

Date of Birth

SS No.

Address

City

State

Zip

Employer

State ID / Driver's License No.

Email address

Name of Physician

Physician Phone

In case of Emergency Contact

Relationship

Phone

How did you hear about our office?

PATIENT HEALTH HISTORY

What type(s) of Hepatitis/Liver disesase?

MEDICAL QUESTIONS

List any medications you are taking including nonprescription drugs

If yes, Please list below

Date of last medical exam

If yes, what was the problem

If yes, Please elaborate

FOR WOMEN ONLY

Expected delivery dateDate

NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control

Dental History Information

Date of last dental visit?

Name of your previous dentist

Reason for today's visit?

How often do you floss your teeth?

If you could change something about your smile what would it be:

Whiter

Straighter

Close space

replace black mercury filling with tooth colored restorations

repair chipped teeth

replace missing teeth

less gums showing

replace old crowns or caps that don’t match

I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient / Signature

Date

Parent/Guardian (if patient is a minor):

Date

PAYMENT ARRANGEMENT FORM

Name of Patient

Date

Payment Agreement:

I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney’s fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.

RESPONSIBLE PARTY

Full Name

Date of Birth

SSN #

Street Address

City

State

Zip

Home Phone

Work Phone

Employer Name

INSURANCE INFORMATION

Add new row

I acknowledge having received a copy of the Practice’s Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

Signature of Responsible Party

(to be signed even if Patient is also the Responsible Party

Date

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