New Patient Form - Cosmetic Dentist in Little Italy

PATIENT INFORMATION

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.

New Patient Form

Title

First Name

Last Name

Sex

Date of Birth

Address

Text Input

Employer

Occupation

CONTACT INFORMATION

Home Phone

Work Phone

Mobile Phone

Email Address

Emergency Contact

Phone Number

Family Doctor

Phone Number

REFERRAL SOURCE

How did you hear about us?

INSURANCE INFORMATION

Do you have Dental Insurance?

Yes

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

Company Name

Primary Policy Holder's Employer

Group Number

Certificate Number

Insurance Year End

Annual Coverage

% Coverage For

Basic

Major

Secondary Insurance Information (if applicable)

Name of Insured

Patient's Relationship to Insured

Date of Birth

Company Name

Secondary Policy Holder's Employer

Group Number

Certificate Number

Insurance Year End

Annual Coverage

% Coverage For

Basic

Major

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

Checkbox Field

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

PATIENT INFORMATION

CONTACT INFORMATION

REFERRAL SOURCE

INSURANCE INFORMATION

CANCELLATION POLICY

ASSIGNMENT AND RELEASE

Clinton Dental

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Book Appointment

Fill the form below to book an appointment or call (833) 478-4371