Lawrence Dental Solutions

Welcome - Thank you for selecting our dental health team! We will strive to provide you with the best possible dental care. To help us meet your dental healthcare needs, please fill out this form completely. If you have any questions we will be happy to help.

Patient Information

*Patient Name:

Last name

Mid name

First name

Date of Birth:

*Address:

				City
State		Zip		APT#

*Home phone #:	()- -	Cell #:	()- -
Work phone #:	()- - -

*Email Address:

Whom may we thank for referring you?

Person to contact in case of emergency:

Responsible Party Details -

His/Her Name:

Relationship:

Address:

				City
State		Zip		APT#

Insurance Information

Primary Insurance Information-

Policy Holder:

Birthday:

Social security#:

Relationship :

Insurance Co.:

Name of Employer:

Group Number #: ID Number #:

Address:

				City
State		Zip		APT#

Secondary Insurance Information-

Policy Holder:

Birthday:

Social security#:

Relationship :

Insurance Co.:

Name of Employer:

Group Number #: ID Number #:

Address:

				City
State		Zip		APT#

Release


*	I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.


*	I authorize the release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits as well as other dentists.

I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full on all accounts. By signing this statement, I agree to be responsible for payment of services not paid, in whole or in part by my dental care payor. I understand that payment is due at time of service unless other arrangements have been made. Should it become necessary to incur collection expenses for payment of the balance of monies owed, I shall be responsible for payment of interest at 18% annum on the unpaid balance and shall be responsible for the cost and expenses of collection, including, but not limited to, attorney’s fees.

*Signature:		Date:
(Your digital signature (full name) is as legally binding as a physical signature.)