Download Document

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