In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

NOTE: Fields marked with an asterisk (*) are required.

PATIENT INFORMATION

Title:

Patient Name:*

Date of Birth:*

Sex:

Address:*

Employer:
Occupation:
CONTACT INFORMATION
Emergency Contact:*
Phone Number:*
Family Doctor:
Phone Number:
REFERRAL SOURCE
How did you hear about us?
INSURANCE INFORMATION
Do you have Dental Insurance?* Yes   |   No

If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Information

Name of Insured:

Patient's Relationship to Insured:

Date of Birth:

Insurance Provider

Insurance Year End:

% Coverage For:

Secondary Insurance Information (if applicable)

Name of Insured:

Patient's Relationship to Insured:

Date of Birth:

Insurance Provider

Insurance Year End:

% Coverage For:

CANCELLATION POLICY

We will make every attempt to schedule your appointments at your convenience. When an appointment is booked, that time slot is set aside just for you. For this reason if you are unable to keep a scheduled appointment, 2 business days notice is required or a fee of $100 will be charged to your account, which must be paid prior to your next visit.

ASSIGNMENT AND RELEASE

 I am financially responsible for any balances due on the day of treatment, and I authorize the dentists to release any information for this claim to the insurance company on my behalf if applicable. I authorize that my dental records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office I am obligated to pay said office in accordance with its credit terms and policy. I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

Patient Name*:
Date*:
Patient Initials*: