Chart #:
FOR OFFICE USE ONLY
Patient Information
Patient Name: Date:
Last, First MI (Preferred Name)
Male Female Married Single 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
Health Information
Date of Last Dental Visit: Reason for this visit:
Have you ever had any of the following? Please check those that apply:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
___________________ |
|
|
|
|
|
|
Due date: |
|
|
|
|
|
|
|
|
|
|
OTHER: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Have you ever had any complications following dental treatment? Yes No
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? 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 doctors 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: Tom Baber
Spouse or Responsible Party Information
The following is for: the patient's spouse the person responsible for payment
Name:
Male Female Married Single Child Other
Social Security #: Birth Date:
Phone (Home): ___________ (Work): Ext: Best time to call:
Address:
Street Apartment #
City State Zip Code
Employment Information
The following is for: the patient's spouse the person responsible for payment
Employer Name: Occupation:
Address:
Street City, State Zip Code Phone
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.
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 and I further agree to pay all costs and 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.
I have read the above conditions of treatment and payment and agree to their content.
Date: Relationship to Patient:
Signature of patient, parent or guardian
Date: Relationship to Patient:
Signature of guarantor of payment/responsible party