Chart #: __________

FOR OFFICE USE ONLY

Patient Information

Patient Name: __________________________________________(______________) Date: _______________

Last First MI Preferred Name

Male Female Married Single Divorced Widowed Child Other _____________

Social Security #: ________________________________ Birth Date: _________________________________

Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call: _____________

Preferred appointment times: Morning Afternoon Evening Any Time M T W T F S

Address: __________________________________________________________________________________

Street Apartment # City State Zip Code

In case of emergency, who should be notified?________________ __Relationship_______Phone_____________

Health Information

Date of Last Dental Visit: __________________ Reason for this visit: ___________________________________

Have you ever had any of the following? Please check those that apply:

AIDS	Artificial Joints	Nervous Disorder	Respiratory Problems
Arthritis	Diabetes	Radiation Treatment	Stomach Problems
Rheumatism	Head Injuries	Sinus Problems	Ulcers
Cancer	Thyroid Problems	Tumors	Penicillin Allergy
Excessive Bleeding	Mental Disorders	Anemia	Codeine Allergy
Hay Fever	High Blood Pressure	Blood Disorder	Latex Allergy
Hepatitis	Tuberculosis	Epilepsy	OTHER:
Liver Disease	Asthma	Growths	_______________
Pregnant? Due:	Dizziness	Mitral Valve Prolapse	_______________
Rheumatic Fever	Glaucoma	Heart Murmur	_______________
Stroke	Heart Disease	Kidney Disease	_______________
Venereal Disease	Jaundice	Pacemaker

CURRENT MEDICATIONS: ______________________________________________________________________________________________________________________________________________________________________________________

Have you ever had any complications following dental treatment? Yes No

If yes, please explain: _______________________________________________________________________

Are you now under the care of a physician? Yes No

If yes, please explain: ______________________________________________________________________

Name of Physician: _______________________________________________ Phone: ___________________

Do you have any health problems that need further clarification? Yes No

If yes, please explain: ______________________________________________________________________

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail.

_________________________________________________________________ Date: ___________________

Signature of patient, parent or guardian

Referral Information

Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative

Dental Office Yellow Pages Newspaper School Work Other__________________

Name of person or office referring you to our practice: ______________________________________________

Spouse or Responsible Party Information

The following is for: the patient's spouse the person responsible for payment

Name: ____________________________________________________________________________________

Male Female Married Single Divorced Widowed Child Other _____________

Social Security #: ________________________________ Birth Date: _________________________________

Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call: _____________

Address: __________________________________________________________________________________

Street Apartment # City State Zip Code

Account will be paid by:___CASH___CHECK___Visa/MasterCard/Discover___Dencharge (CareCredit)___

PLEASE NOTE: ALL CHARGES DUE AT TIME OF SERVICE. If insurance in effect, please let us know prior to treatment.

Employment Information

The following is for: the patient the person responsible for payment How long employed?___________

Employer Name: ____________________________________ Occupation: _____________________________

Address: __________________________________________________________________________________

Street City State Zip Code

Insurance Information

Primary

Name of Insured: _______________________________________________ Is insured a patient? Yes No

Last First MI

Insured's Birth Date: _________________ ID #: _____________________ Group #: _____________________

Insured's Address: ___________________________________________________________________________

Street City State Zip Code

Insured's Employer Name: ____________________________________________________________________

Address: ___________________________________________________________________________

Street City State Zip Code

Patient's relationship to insured: Self Spouse Child Other___________________

Insurance Plan Name and Address: ____________________________________________________________

____________________________________________________________

Secondary

Name of Insured: _______________________________________________ Is insured a patient? Yes No

Last First MI

Insured's Birth Date: _________________ ID #: _____________________ Group #: _____________________

Insured's Address: ___________________________________________________________________________

Street City State Zip Code

Insured's Employer Name: ____________________________________________________________________

Address: ___________________________________________________________________________

Street City State Zip Code

Patient's relationship to insured: Self Spouse Child Other___________________

Insurance Plan Name and Address: ____________________________________________________________

____________________________________________________________

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

INSURANCE AUTHORIZATION/ASSIGNMENT: I hereby authorize the doctor to furnish information to insurance carriers concerning my treatments and I hereby assign to the dentist all payments for medical services rendered to myself or my dependents. I understand I am responsible for any amount not covered by insurance. I further agree to pay all costs and reasonable attorney fees that are incurred in attempts to collect any unpaid balance.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and agree to their content.

____________________________________________________ Date: _____________ Relationship to Patient: _____________________

Signature of patient, parent or guardian