Personal Information Form

Please note that it is important to fill in all the fields before submitting. Thank you.


Last Name* :
First Name :
Middle Name :
SSN :

Gender : DOB :
Home address :
City :
State :
Zip :

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 :    
Emergency Contact Person ( Other than your family home)
Name:
Relationship :
Home Phone: ()- -
Work Phone : ()- - -
Cell Phone : ()- -
 
Other family members that are patients here :
Name
 
 
Insurance And Financial Information
Insurance Coverage? Yes   No
Primary Insurance Co
Address
City
State
Zip
Phone
()- -
Policy#
Group #
Subscriber's Name
Subscriber's SSN
Subscriber's Birthday
Relation to Patient
Subscriber's Employer
Employers Address
City
State
Zip
Seconday Insurance Coverage? Yes   No
Secondary Insurance Co
Address
City
State
Zip
Phone
()- -
Policy#
Group #
Subscriber's Name
Subscriber's SSN
Subscriber's Birthday
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.
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 only accept PPO insurances. 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 :