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Personal Information Form

Please note that it is important to fill in all the fields before submitting. Thank you.
*Last Name :
Middle Name : *First Name :
Social Security #:
Gender : Male Female Date of Birth :
Home Address
City :
State : Zip :
Apt.#
*Home Phone : ( )- -
*Email :
Marital Status : Single Widowed Married Divorced Under 18 Guardian's Name :
Patient's / Guardian's Employer : Occupation :
Work Address City :
State : Zip :
Cell Phone : ( )- -
Work Phone : ( )- - -
Ok to call work? Yes No
Referred by :
Spouse's Information
Spouse's Last Name: Middle Name : First Name :
Spouse's Employer : Occupation :
Work Address City :
State : Zip :
Cell Phone : ( )- -
Work Phone : ( )- - -
Ok to call work? Yes No
Emergency Contact Person ( Other than your family home)
Name : Relationship :
Home Phone : ( )- -
Cell Phone : ( )- -
Work Phone : ( )- - -
Other family members that are patients here :
Insurance And Financial Information
Primary Insurance
Insurance Coverage? Yes No
Insurance Co :
Address :
City
State Zip
Phone : ( )- -
Policy # :
Group # :
Subscriber's Name :
Subscriber's SSN :
Subscriber's DOB :
Relation to Patient :
Subscriber's Employer
Employers Address :
City
State Zip
Secondary Insurance
Insurance Coverage? Yes No
Insurance Co :
Address :
City
State Zip
Phone : ( )- -
Policy # :
Group # :
Subscriber's Name :
Subscriber's SSN :
Subscriber's DOB :
Relation to Patient :
Subscriber's Employer
Employers Address :
City
State Zip
* I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balance due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he determines.
* In consideration of the services rendered to me by the dental office I am obligated to pay said office in accordance with its credit terms and policy.
* I consent to the making of videotapes, photographs, and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations.
* I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
Customized Personality Profile
In order to serve you better and to give you the individual attention you deserve please check the appropriate responses
I have a fear of - I have concerns about :
Experiencing pain Not being numb Needles Having something put over my mouth
Gagging Losing Control Unnecessary or Wrong treatment Being scolded or made to feel ashamed
Catching a disease Losing my teeth Having to wear a denture or partial Other
When I think about coming to the dentist I feel :
Comfortable- I have no anxiety about seeing the dentist or dental procedures.
Anxious- I don't want to come but I make myself, however I am seldom comfortable.
Fearful- I have stayed away from the dentist because of my fear and avoid coming unless absolutely necessary.
Extremely Fearful- I cannot cope with dental visits and have avoided the dentist for years to the detriment of my dental health.
The following makes me uncomfortable :
Being numb The sounds of dental drill Laying down in a dental chair The smell in a dental office
Having to wait in the reception area Other
I have avoided the dentist because of :
Anxiety and fear Budget Concerns Time Concerns No Sense of Urgency
Lack of Trust Other
To understand what's going on in my mouth, my preference is :
To know all the details To be given the bottom line To read pamphlets and brochures
To be shown pictures and movies To talk with a team member about solutions to my problems
My childhood dental experiences were :
Traumatic Painful Somewhat uncomfortable Completely pain free and comfortable
I did not go to the dentist as a child
My dental experiences as an adult have been :
Traumatic Painful Somewhat uncomfortable Completely pain free and comfortable
I have not seen a dentist as an adult or my visits have been very few.
My immediate concern about my teeth and my smile is :
Financial Policies
We offer 5% discount to all patients that pay IN FULL by cash or check for ALL SERVICES/TREATMENT before at the time of service.
  • It is each patient responsibility to make a determination if they have active insurance coverage. Patients that receive treatment and later find out they are not active are responsible for the full amount of services provided.
  • We service over 200 different insurance policies. It is impossible for us to determine the amount that the insurance company pays for services and if the insurance company will pay at all. Insurance reimbursements estimates are just that, estimates. We do not guarantee payment amount or payment at all. Please be aware we are an insurance friendly office and will go to great lengths to see that you are reimbursed by your insurance company but we do not guarantee any reimbursement or amount of reimbursement.
  • For patients who choose to have us bill insurance and are unwilling to pay the full amount at the time of service, and would rather wait for reimbursement, we require a credit card on file in the event that the insurance company fails to pay or insufficient payment is received. At the receipt of insurance reimbursement and explanation of benefits the patient will be informed that the remaining balance will be placed on their card before the card is charged.
  • We work with all insurance companies, when you arrive our office will be happy to do a complimentary benefits check for you, we will bill the insurance for the patient after the service is started/completed.
  • In the event that an insurance company overpays or pays the amount to us when it is owed to the patient we will reimburse the patient within 2 business days.
  • In the unfortunate event of failure to pay outstanding bills in a timely manner we will reserve the right to turn the amount over to a credit agency and/or withhold services.
* I certify that I have read the above listed financial policies and fully understand its content.
ACKNOWLEDGEMENT OF RECEIPT OF: Privacy Practices Notice and Dental Material Fact Sheet
This document acknowledges that you have received or declined a copy of:
- Notice of Privacy Practices
- Dental Material Fact Sheet
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This document is not a contract, authorization, release or consent form. This document will remain in your records.
I acknowledge that I have received a copy of the Notice of Privacy Practices and the Dental Material Fact Sheet.
I acknowledge that I have declined to take a copy of the Notice of Privacy Practices and the Dental Material Fact Sheet.
*Signature :
Date :