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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 .