Patient Information Form

Name 												 Date 			
			First		Middle			Last
Address 							 City 				 State 		 Zip 		
Cell # 			 Home phone 			 Soc. Security # 				 Birthdate 		
Email 															
If college student, F.T/P.T., name of school 						 City 			 State 		
Patient or parent’s employer 						 Work phone 				
Business address 				 City 				 State __	 Zip 			
Spouse or parent’s name 				 Employer 			 Work phone 				
Whom may we thank for referring you 											
Person to contact in case of an emergency 						 Phone 					

Responsible Party

Name of person responsible for this account 						 Relationship to patient 			
Address 										 Home phone 				
Driver’s license # 					 Birth Date 			 Soc. Security # 				
Employer 									 Work phone 				
Is this person currently a patient in our office	   Yes	   No

Insurance Information

Name of insured 									 Relationship to patient 			
Birthdate 				 Soc. Security # 				 Date employed 				
Name of employer 				 Union or local # 			 Work phone 				
Employer address 				 City 				 State 		 Zip 			
Insurance Co. 						 Tel. # 			 Grp. # 		 Policy/I.D.# 		
Do you have any additional insurance    Yes    No	If yes, complete the following:
Name of insured 					 Soc. Security # 				 Date employed 			
Name of employer 				 Union or local # 				 Work phone 			
Employer address 				 City 					 State 		 Zip 		
Insurance Co. 					 Tel. # 			 Grp. # 		 Policy/I.D. # 	_________	

X											
Signature of patient (or parent, if minor)						                

Office Policies

FEES - The fee for your treatment is based on the complexity of your case.  You will be informed of the fee after your examination.

PAYMENT – It is our policy that payment for all services rendered be made in full AT or BEFORE the completion of treatment.  We realize that some dental treatment may be of an emergency nature, and that patients may not always be prepared for unexpected dental expenses.  To assist you in this regard, we gladly accept VISA, MASTERCARD.

DENTAL INSURANCE – If you believe that your treatment is covered by a dental insurance policy, we will be happy to assist you in completing the necessary forms.  Please understand that while this is done for your convenience, we consider each patient to be responsible for their entire balance regardless of their insurance coverage. 

If your insurance carrier will reimburse you directly, we ask that your account with our office be paid in full when treatment is rendered.

MISSED APPOINTMENTS – Confirmed appointments require 24 hour notice if you are unable to be present.  You will be assessed a MISSED APPOINTMENT FEE of $50.

X															
    Signature of patient (or parent, if minor)							Date