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Patient Information Name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date of Birth: Spouses Narne: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Parents Name (if child): _ _ __ Address: Email: ----------------- Employed by·~_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Home#: (_L)_ _ _ __ Best time to call: Cell #: ( ---/)'---_ _ __ --------------- Sex: Male or Wo~#:(~_)~ Female _______ ----------------Person Ultimately Responsible for the Account Name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Relation_'_ _ _ _ _ _ __ Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ Cell #: ( --<..)_ _ _ __ Home #:(- ' -)- - ' - - - - - - Work #: .!--(---.::..)_ _ _ __ Date ofBirth_·_ _ _ _ _ _ _ _ __ Primary Dental Insurance Please Circle One of the Following: or MEDICAID EDS NC Healthchoice Recipient 1.0.# or Subscriber 1.0.#_:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Person to Contact in Case of an Emergency Name: _ _ _ _ _ _ _ _ _ _ _ _ _ __ Home #:(.....--<)_____ Work #:( ) Relation: Cell #: ( _-...J-_ _ _ _ _ __ Referral information Whom may we thank for referring you to our practice? o Another Patient 0 Friend or Relative o Newspaper o School o Work Other: o o Yellow Pages Dental Office ***PLEASE COMPLETE THE CONSENT FORM ON THE BACK OF nns SHEET*** Consent for Services As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and fmancial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous fmancial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms orassist in making collections for insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of IYl% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 45 days, unless previously written financial arrangements are satisfied. I hereby authorize the Dental Office to administer such medications and perform diagnostic, photographic, and therapeutic procedures as may be necessary for proper dental care. I grant the right to the dentist to release my dentaVmedical histories and other information about my dental treatment to their party payers and/or health professionals. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form, my dental treatment, to schedule appointments and to be reminded of any scheduled appointments. I understand that the fee estimate listed for this dental care can only be extended for a period of six months for the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be billed unless objected by me, in writing. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content Signature of Patient, Parent or Guardian Date Relationship to patient Signature of Guarantor of PaymentlReasonable Party Date Relationship to patient