PATIENT INFORMATION

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

*Patient Name :

*Last Name

Middle name

*First name

*Your birthday :

Age:

Sex : MaleFemale

*Home address :

	City		State
	Zip		APT#

*Email address :

Social security# :

Telephone :

*Home:

()--

Work :

()---

Cell :

()--

Employed By :

Work address :

	City		State
	Zip

Occupation :

Have you explored our website? YesNo

How did you hear about us? Whom may we Thank for referring you?

Spouse/Parent name :

Social security# :

Employed by :

Work Phone :

()---

Work Address :

	City		State
	Zip

In case of emergency :
Relative to contact other than spouse/parent :	Phone :	()--

Address :

	City		State
	Zip		APT#

Current Physician :

Phone :

()--

INSURANCE INFORMATION

A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the patient’s account and the patient or person responsible for the account is responsible for payment of all fees incurred. For your convenience, we will gladly assist you in submitting insurance claims pertaining to any charge for care in our office.

Insured’s name :

Birthday :

Relationship :

Social security# :

Insurance Co. name:

Phone :

()--

Address :

	City		State
	Zip

Policy# :

Member ID Number :

Insured’s employer :

Phone :

()--

Address :

	City		State
	Zip

Secondary Insurance Information : If you have NO secondary insurance check here

Insured’s name :

Birthday :

Relationship :

Social security# :

Insurance Co. name :

Phone :

()--

Address :

	City		State
	Zip

Policy # :

Member ID Number :

Insured’s employer :

Phone :

()--

Address :

	City		State
	Zip

FINANCIAL INFORMATION

If someone other than the patient is responsible for payment complete the following :

Name of Responsible Party :		Social security# :
Relationship to patient :

Address :

	City		State
	Zip		APT#

Employed by :

Address :

	City		State
	Zip

Home Phone :

()--

Work Phone :

()---

* I, the undersigned, authorize direct remittance of (surgical, medical, dental) benefits, if any, otherwise payable to me for services rendered. I acknowledge that I am financially responsible whether or not paid by insurance. If it becomes necessary to effect collections of amount, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize the doctor to release information necessary to secure the payment of benefits.

*Signature :

Date :

If any of the above information changes during the course of your treatment, please notify us immediately
*There will be a finance charge on account balances over 90 days.