Dr. J. Belsito

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health.

Personal Information

Surname:

First:

Date of Birth:

Gender:

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Female

Address:

City:

Postal Code:

Occupation:

Employer:

Address:

Phone (Res):

Phone (Bus):

Phone (Cell):

Email:

Family Physician:

Phone (Bus):

Date of Last Exam:

Marital Status:

Health Card #:

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Name of Spouse, Parent or Guardian:

Occupation:

Employer:

Address:

Phone (Res):

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Emergency Contact:

Relationship:

Phone Number:

Whom may we thank for referring you to our practice?

Another Patient

Doctor

Staff

Online / Social

Magazine

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Other:

Insurance Information

Do you have dental insurance?

Yes

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Name of Insured:

Insured Date of Birth:

Insurance Company:

Group #:

ID #:

Driver's License #:

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This information is collected to verify identity and settle any account balances not covered by insurance.

Secondary Insurance Information

Do you fall into another family member's dental insurance?

Yes

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Name of Insured:

Insured Date of Birth:

Insurance Company:

Plan/Contract/Group #:

Certificate/ID #:

Driver's License #:

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This information is collected to verify identity and settle any account balances not covered by insurance.

Health Information

Do you have any other health concerns?

Dental Information

Any other dental conditions:

Reasons for todays visit:

Former Dentist:

City:

Province:

Date of last dental visit:

Date of last dental x-rays:

How often do you brush:

How often do you floss:

Medication

List of medication(s) you are currently taking:

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Pharmacy Name:

City/Province:

Phone:

Authorization

I, the undersigned patient, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information.

I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. This includes all levels of sedation including nitrous oxide (laughing gas) oral sedation and IV (sleep) sedation.

Unless other arrangements are made, payment is due at each office visit. My dental insurance is a contract between myself and the insurance company, not between my insurance company and the dentist.

I will assume full responsibility for the fees associated with these procedures.

I am aware that 2 business days notice is required to change or cancel an appointment without charge.

I agree that Dr. Joseph A. Belsito & Associates can collect, use and disclose personal information about myself or my dependents as set out in the office's privacy policies, and consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. I further agree to receive electronic messages, including text messages, in regards to communicating appointments, requests, information, products, promotions, company news and updates which can be withdrawn at any time. I further consent to being videotaped in public areas of the dental office.

Patient / Parent / Guardian

Date

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