Minor Health History

Please correct the errors described below.

IN CASE OF EMERGENCY PLEASE CONTACT (Someone not living with you)

ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with the above the insurance company and assign directly to the doctor otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. Patient portion due at the appointment. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions

Patient portion due at appointment

DIVORCE: In case of divorce or separation, the parent accompanying the child and authorizing treatment will be the parent responsible for the charges on the day of service. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

DENTAL HISTORY

(Cardiac, Orthopedic, Oncologist, etc,.)

Please check Yes or No to indicate if you have had any of the following:

MEDICATIONS

I understand I am responsible for my account balance regardless of my insurance. I also understand that my insurance is an agreement between my insurance company and myself. WP Dental will prepare and submit necessary forms to help you obtain your benefits.

I understand that I may be charged a 1% finance charge per month (12% annually) if my balance goes beyond 60 days from date of service not from date the insurance company pays my benefits. Patient portion due at appointment.

I give permission for my dentist and clinical team to take any necessary radiographs, study models, and photographs to make a complete diagnosis of my dental needs. I also give permission for my dentist and dental team to use my photographs for in-office patient education.

I consent to the use and disclosure of my protected health information to obtain payment information in connection with my dental claims.

(I have read, agree to, and understand the statements listed above.)

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