Confidential Patient Information

Patient Name

Date of Birth

Home Address

City/Town

State

Zip

Home Phone

Mobile Phone

Work Phone

Social Security Number

Emergency Contact

Phone

Name of Person Responsible for this Account

Relationship

Home Address

City/Town

State

Zip

Home Phone

Mobile Phone

Work Phone

Social Security Number

Date of Birth

Dental Insurance Information

Name of Policy Holder

Relationship

Date of Birth

Social Security Number

Insured Subscriber Number

Group Number

Name of Employer

Phone

Name of Insurance Company

Address

City/Town

State

Zip

Insurance Company Phone

Fax

Additional Dental Insurance

Yes No

If yes, please complete the following:

Name of Policy Holder

Relationship

Date of Birth

Social Security Number

Insurance Subscriber Number

Group Number

Name of Employer

Phone

Name of Insurance Company

Address

City/Town

State

Zip

Insurance Company Phone

Fax

I/(patient/parent/guarantor/guardian), understand and acknowledge I am financially responsible for the dental insurance deductible, co-payments, and all dental fees NOT covered by the dental insurance plan associated with my dental care/treatment, and all services provided by the dental team of Dr Gerald M. Winkler. I am aware that if I do not have dental insurance, all services rendered are my financial responsibility.

Accounts 60 days past due will be handled by our Accounts Receivables Partner - TekCollect. I understand a collection fee will be assessed to my account and become my responsibility as well.

I hereby authorize any/all insurance payments to Dr. Gerald M. Winkler. I fully grant the right to the dentist and dental team members to release my dental/medical histories, X-rays, and any other information about my dental treatment to third party payor and/or other health professionals associated with my care by any method, including postal mail, fax, and electronic transfer.

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

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