Clerical Information Update

Title:

Mr. Mrs. Ms. Dr.

First Name:

MI:

Last Name:

Street Address:

City:

State:

Zip:

Home Tel #:

Cell #:

Work #:

Email:

[For your convenience, you will receive your appointment reminders via text and/or email. Please provide us with your most current information.]

Emergency Contact Name:

Phone:

Has there been any change to your insurance information?

Yes No

If yes, please fill in the following information and present new insurance card (if available) to the front desk.

Name of Subscriber:

Employer of Subscriber:

Name of Insurance Company:

Policy/Group Number:

Subscriber ID Number:

Permission for Dental Examination and Treatment

I do hereby authorize and consent to any x-rays, examination, anesthetic, or dental treatment rendered under the general, direct, or indirect supervision of Dr. Siao and/or staff members they may deem necessary. This authorization will remain in effect until cancelled in writing by me.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Parent/Guardian Signature:

Date:

Your information will be encrypted.