Patient Information

    Phone


    Health Information

    AIDSAllergiesAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsy

    Excessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver Disease

    Mental DisordersNervous DisordersPacemakerPregnancyRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosis

    TumorsUlcersVenereal DiseaseCodeine AllergyPenicillin AllergyBisphosphonates

    Have you ever had any complications following dental treatment?

    YesNo

    If yes, please explain:

    Have you been admitted to a hospital or needed emergency care during the past two years?

    YesNo

    If yes, please explain:

    Are you now under the care of a physician?

    YesNo

    If yes, please explain:

    Do you have any health problems that need further clarification?

    YesNo

    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 doctors at the next appointment without fail.

    What would you like to change about your smile?

    Referral Information

    Whom may we thank for referring you to our practice?

    Another patient, friendAnother patient, relativeDental OfficeYellow PagesNewspaperRadio StationWorkCare CreditOther

    Name of person or office referring you to our practice:

    “Do you know about our New Patient Referral Program”?

    YesNo

    Responsible Party Information

    The following is for:

    The following is for:the person responsible for payment

    Same as front sheet


    MaleFemaleMarriedSingleChildOther

    Phone

    Your Employment Information

    Insurance Information

    Primary Insurance

    Patient's relationship to insured:

    SelfSpouseChildOther

    Insurance Plan Name and Address:

    Secondary Insurance

    Patient's relationship to insured:

    SelfSpouseChildOther

    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 treatment plan estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

    In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at
    the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by
    me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition. I
    further agree to pay all costs (including an additional 50% of balance) and any reasonable attorney fees if suit be instituted hereunder.

    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.

    This office is HIPPA compliant. We use and disclose health information about you and/or family members for purposes of treatment, payments, and dental practice operations only. Our
    patients are welcome to request copies of our office privacy policies at any time.

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