Pinnacle Orthodontics

Date:

Home Phone:

Cell Phone:

Patient Last Name:

First Name:

Middle Initial:

Date of Birth:

Address:

City:

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Zip Code:

Sex:

Male Female

SS#:

(Required if 18 & Older)

Employer:

Employer Phone:

In case of emergency, contact:

Phone Number:

How did you hear about our office: (Select One)

Dr. Referral Insurance Phone Book Friend/Relative Other

Dentist:

Phone Number:

Doctor:

Phone Number:

IF PATIENT IS 18 YEARS OF AGE & UNDER COMPLETE THE FOLLOWING

Father’s Name:

Date of Birth:

SS#:

Address:

City:

State:

Zip Code:

Employer:

Employer Phone #:

Business Address:

City:

State:

Zip Code:

Mother’s Name:

Date of Birth:

SS#:

Address:

City:

State:

Zip Code:

Employer:

Employer Phone #:

Business Address:

City:

State:

Zip Code:

INSURANCE INFORMATION

Primary Dental Insurance:

Subscriber:

Address:

Phone Number:

Secondary Dental Insurance:

Subscriber:

Address:

Phone Number:

MEDICAL HISTORY

If you checked Other, please specify:

List all drug allergies:

Have you ever had an adverse reaction to medications?

Yes No

Have you been in an accident injuring the face, jaw, or head?

Yes No

Have you had any adverse reaction to medical/dental treatment?

Yes No

List medications you are taking:

(Women) Are you pregnant?

Yes No

Are you nursing?

Yes No

I, the undersigned, having insurance benefits and assign directly to Dr. Robert Pham all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electric.

I, being the parent/guardian of the child do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to X-rays, whether or not I am present at the actual appointment when treatment is rendered.

I, acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parent/guardian are responsible for all fees/services rendered for treatment of a minor/child. I accept full financial responsibility for all the charges not covered by insurance.

The above information is accurate and complete to the best of my knowledge and is only for the use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form

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

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