Download patient information form - Loveland Family Dentistry

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PATIENT INFORMATION
DATE_______________________________
NAME_________________________________________________
Last
First
M
□Married □Single □Minor □Male □Female
SOCIAL SECURITY # ________________________________ BIRTHDAY __________________________________________________
Month
Day
Year
ADDRESS____________________________________________________________________________________________________
Street
Apt #
City
State
Zip
TELEPHONE _________________________________________________ EMAIL___________________________________________
Home
Work
Cell
NAME OF EMPLOYER_______________________ ADDRESS____________________________________PHONE__________________
IF FULL TIME STUDENT, SCHOOL NAME: _______________________________________________GRADE______________________
PERSON RESPONSIBLE FOR ACCOUNT-Please check one:
□ Patient □ Guardian □Mother □Father
INSURANCE INFORMATION
PRIMARY INSURNED/ IF NO INSURANCE COMPLETE
SECONDARY INSURED
FOR RESPONSIBLE PARTY
________________________________________________
_______________________________________________
Last
Last
First
M
First
M
___________________________________________________________
Street
City
State
Zip
__________________________________________________________
Street
City
State
Zip
__________________________________________________________
Phone: Home
Work
Cell
__________________________________________________________
Phone: Home
Work
Cell
________________________________________________
________________________________________________
Birthdate ( mo/day/year)
Relationship to Patient
___________________________________________________________
Employer
Dental Insurance Co.
Phone #
___________________________________________________________
SS#
ID#
Group #
Birthdate (mo/day/year)
Relationship to Patient
___________________________________________________________
Employer
Dental Insurance Co.
Phone #
___________________________________________________________
SS#
ID#
Group #
PERSON TO CONTACT IN CASE OF EMERGENCY
Has any member of your family ever been treated in our office?
□ Yes
Name_________________________________________________
□ No
Whom may we thank for referring you to our office?
Address_______________________________________________
City/State/Zip__________________________________________
______________________________________________
METHOD OF PAYMENT
Responsible party currently has an account with this office
Telephone # ___________________________________________
AUTHORIZATION
□ Yes
□ No
□ Payment in full at each appointment □Visa □MC □Other
I hereby authorize payment directly to the Dental Office of the group
Insurance benefits otherwise payable to me. I understand that I am
Card#_______________________________Exp:_________Cvd_____
responsible for all cost of dental treatment. I hereby authorize the Dental
Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may need to be necessary for
proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the
dentist to release my dental/medical histories and other information about my dental treatment to a third party payor and/or health professionals.
______________________________________________________________________
PATIENT OR RESPONSIBLE PARTY
_____________________________________________
DATE
.
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