Patient Information Form

Last Name

First Name

Middle Initial

Preferred Name

Date

Social Security #

Birth Date

Email address

Please confirm future appointments by

Email Text Phone Call

Phone (Home)

Work Phone

Ext

Phone (Cell)

Address

City

State

Zip Code

Spouse or Responsible Party Information

The following is for

The patient's spouse The person responsible for payment

Last Name

First Name

Middle

Social Security #

Birth Date

Home Phone

Work Phone

Ext

Best time to call

Address

City

State

Zip

Employment Information

Employer Name

Occupation

Insurance Information Primary

Name of Policy Holder

Policy Holder Date of Birth

ID #

Group #

Name of Insurance Plan

If other, please specify

Insurance Information Secondary

Name of Policy Holder

Policy Holder Date of Birth

ID #

Group #

Name of Insurance Plan

If other, please specify

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for the payment of all dental services. This office will help prepare the patient's insurance gonna or assist in realizing collections from insurance companies and will credit any such collections to the patient's account, However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs, collection fees, and reasonable attorney fees if the suit is instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.

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 of Patient, Parent or Guardian

Date

Relation to Patient

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