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PATIENT INFORMATION DATE:________________________ NAME:____________________________________________________________ MARRIED SINGLE MINOR / MALE FEMALE LAST FIRST MI NAME PREFERENCE __________________________________________________ ADDRESS:_____________________________________________________________________________________________________ STREET APT.# CITY STATE ZIP BIRTHDATE:____________________________ TELEPHONE: ___________________________ ____________________________ MO DAY YR Home Cell EMAIL: __________________________________________ (We use this for patient communications ONLY. Your information will NEVER be given out to others) Social Security #_________________________________________State Drivers License .#_________________________________________________ EMPLOYER / SCHOOL:______________________________________________________________________________________________________ NAME STREET Has any member of your family been treated in our office? ZIP YES NO Phone Number Relationship_________________________________________ How did you hear about our office?______________________________________________________________________________________________ May we publish your name in our Patient Newsletter? _______________________________________________________________________________ FAMILY INFORMATION HUSBAND (FATHER if minor) WIFE (MOTHER if minor) Name: Last, First, MI Full Address: Telephone Numbers Birthdate / SS #: Employer: PERSON RESPONSIBLE FOR ACCOUNT CHECK ONE: Patient Father (or Husband) Mother (or Wife) Guardian EMERGENCY CONTACT OTHER THAN FAMILY MEMBER Name:_____________________________________________________________ Relationship: _________________________________ Address: __________________________________________________________ Phone #: _____________________________________ METHOD OF PAYMENT Primary Insurance / co-payment in full at each appointment. (Any amounts not paid by my insurance company are my responsibility.) Insurance is filed as a courtesy to patient. Total is ultimately patient’s responsibility. Payment in full at each appointment. (Cash, Check, MC, Visa, American Express or Bank Debit Card) I am interested in applying for dental financing. FINANCE CHARGE. If I do not pay the entire New Balance within 15 days of the monthly billing date, a FINANCE CHARGE will be added to the account for the current monthly billing period. The FINANCE CHARGE will be a periodic rate of 1.5% per month (or a minimum charge of $2.00 for a balance under $134.00) which is an ANNUAL PERCENTAGE RATE of 18% applied to the last month’s balance. In the case of default of payment I agree to reimburse the office the fees of any collection agency, which may be based on a maximum of $11.75, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts. AUTHORIZATION I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history are correct to the best of my knowledge. SIGNATURE OF RESPONSIBLE PARTY The policy in our office, is the parent who requests treatment for a child is responsible for all fees for services rendered. X________________________________________________________________________________________DATE________________ Adult Patient Father (or Husband) Mother (or Wife) Guardian