New Patient Information

In case of emergency who should we notify?

PERSON RESPONSIBLE FOR ACCOUNT BALANCE

Authorization for release of information and responsibility of account

I hereby authorized J.E. Rhodes to release any information regarding myself or services rendered by the practice, to be used to file for any insurance benefits. I understand that I am financially responsible for the fees for all services rendered should my insurance not cover my claim or any portion thereof. I understand that if I do not pay the balance on my account within 90 days that I will be send to collections and will be responsible for an additional collection fee of thirty-three (33%) of the outstanding balance. I am also aware that I will be charged a cancellation fee if I do not give a 24-hour notice when cancelling appointments.

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.

Patient Medical Histroy

Although dental personnel primarily treat the area in and around your mouth. your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an importance interrelationship with the dentistry you will receive. Thank you for answering the following questions.

To the best of my knowledge, the questions on this form have been accurately answered, I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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.