Confidential Information Questionnaire

Patient’s Legal Name

Date of Birth

SSN(US) / SIN(CAN)

Prefer To Be Called

Home Phone #

Cell Phone #

Patient Address

City

State

Zip / Postal Code

Email address

Patient’s / Guardian’s Employer

Occupation

Work Address

City

State

Zip / Postal Code

Work Phone #

Spouse’s Name

Spouse’s Employer

Occupation

Spouse’s Work Address

City

State

Zip / Postal Code

Work Phone #

Other Family Members That Are Patients Here

Who Can We Thank For Referring You To Our Office?

EMERGENCY CONTACT INFORMATION

Person We May Contact In Case Of An Emergency (Other Than Your Family Home)

Name

Relationship

Home Phone #

Work Phone #

Cell Phone #

REQUEST FOR CONFIDENTIAL COMMUNICATION

As My Dental Care Provider, You May Do The Following With My Permission:

INSURANCE AND FINANCIAL INFORMATION

Add new row

RELEASE INFORMATION

YOU MAY DISCUSS MY HEALTHCARE WITH

Others

CONFIRMATIONS

DO YOU PREFER A CONFIRMATION CALL

No, it is unnecessary

Yes, it is a helpful reminder

ASSIGNMENT & RELEASE

I hereby authorize (1) any available insurance benefits to be paid directly to my dentist, (2) the release of my dental health care information for any of my dental health care insurance claim, (3) the use of my dental records by my dentist in any professional manner that he/she determines, (4) the making of videotapes, photographs, and x-rays of my dental care treatment (collectively “My Images”), and (5) my dentist’s use of My Images in scientific papers, demonstrations and/or presentations without compensation to me. I agree that to the extent the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured cost (the “Uninsured Costs”) in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.

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 - Patient / Guardian

Date

Witness Signature

Date

If the above named Patient is a minor or unable to pay the his/her Uninsured Costs, the undersigned agrees to guaranty the payment of such Uninsured Costs to the Patient’s dentist in accordance with his/her payment terms and policies.

Signature - Guarantor Of Patient

Date

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