Patient Update

Medical History, Insurance and Contact Information

Name

Date of Birth

Address

City

State

Zip

Cell Phone No.

Home Phone No.

Work Phone No.

Email address

To help serve our patients, we have a reminder call system in place regarding your appointments. Please indicate your preferred method of appointment confirmation. Check as many as you prefer!

Preferred Confirmation / Contact

Text Email Phone Call Only

HAVE THERE BEEN ANY MEDICAL CHANGES SINCE YOUR LAST VISIT? (Including medications, hospitalization or surgeries)

Yes No

If yes, Please give detailed description of all changes or new medical history.

HAVE THERE BEEN ANY CHANGES TO YOUR DENTAL INSURANCE? If yes, please complete the following and email a copy of your dental card to Frontdesk@theridgewooddentist.com

Yes No

Insurance Carrier

Employer

Subscriber's Name

Date of Birth

Group Number

ID No. (SSN if no ID No.)

ASSIGNMENT AND RELEASE

I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by the dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I certify that I have read or had read to me, the contents of this form and do realize the risks and limitations involved.

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 Guardian Signature

Date

Your information will be encrypted.