Patient Information Form

ACCOUNT INFORMATION

Patient's Full Name

Date of Birth

Single Married Divorced Widowed

Address

City

State

Zip

Home Phone

Cell Phone

Patient's SS#

Driver's License #

Referred By

Employer

Phone

Work Address

Do you prefer to be contacted by e-mail for appointments?

Yes No

Email address

RESPONSIBLE PARTY INFORMATION (unless same as above)

Name

Date

Address

City

State

Zip

Home Phone

Cell Phone

Social Security #

Driver's License #

DENTAL INSURANCE INFORMATION

Name of insured

Date of Birth

SS #

Employer

Work Phone #

Address

City

State

Zip

Ins. Co.

Group #

ID #

Do you have dual Insurance Coverage?

Yes No

By signing this form, I/we authorize the release of information regarding this claim to my insurance carrier or hospitals or other doctors who have treated the patient. I further assign payment directly to this office by signing this form. I acknowledge that I am responsible for all monies due this office not paid by insurance, for the services rendered as described in this/these claim(s). I agree to the office payment/insurance policy. A service charge of 1 1/2 % will be charged on all accounts after 60 days. There is a $25.00 returned check fee.

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.

Signature

Date

Your information will be encrypted.