CONFIDENTIAL INFORMATION AND

DENTAL INSURANCE INFORMATION.

When you arrive for your appointment, we will verify your insurance information. Please bring your identification and current dental insurance cards with you. If you have any questions, please feel free to contact us.

PATIENT INFORMATION
Name *
Name
Patient's Date of Birth *
Patient's Date of Birth
Sex *
Patient's Address *
Patient's Address
Home Phone
Home Phone
Marital Status
Work Address
Work Address
Mobile Phone
Mobile Phone
Work Phone
Work Phone
Is it ok for us to call your work phone?
SPOUSE INFORMATION
Spouse's Name
Spouse's Name
Spouse's Work Address
Spouse's Work Address
Spouse's Mobile Phone
Spouse's Mobile Phone
Spouse's Work Phone
Spouse's Work Phone
Is it ok for us to call your spouse's work phone?
EMERGENCY CONTACT INFORMATION
Person we can contact in case of an emergency (other than your family home)
Person we can contact in case of an emergency (other than your family home)
Home Number
Home Number
Work Number
Work Number
Mobile Number
Mobile Number
Whom can we thank for referring you to our office?
Whom can we thank for referring you to our office?
INSURANCE COVERAGE
Please bring your current dental insurance cards and identification with you to your initial appointment.
PRIMARY DENTAL INSURANCE INFORMATION [if applicable]
Insurance Company Address
Insurance Company Address
Insurance Company Phone Number
Insurance Company Phone Number
Insurance Subscriber's Name
Insurance Subscriber's Name
Patient's Relationship to Subscriber:
Subscriber's Date of Birth
Subscriber's Date of Birth
Employer Address (if different from above)
Employer Address (if different from above)
SECONDARY DENTAL INSURANCE INFORMATION [if applicable]
Do you have secondary dental insurance coverage?
Secondary Insurance Company Address
Secondary Insurance Company Address
Secondary Insurance Company Phone Number
Secondary Insurance Company Phone Number
Secondary Insurance Subscriber's Name
Secondary Insurance Subscriber's Name
Patient's Relationship to Secondary Insurance Subscriber:
Secondary Insurance Subscriber's Date of Birth
Secondary Insurance Subscriber's Date of Birth
Secondary Insurance Subscriber's Employer Address (if different from above)
Secondary Insurance Subscriber's Employer Address (if different from above)
ASSIGNMENT & RELEASE
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my 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 making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the 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.
Electronic Agreement to Assignment & Release *
Electronic Agreement to Assignment & Release
Date of Agreement to Assignment & Release *
Date of Agreement to Assignment & Release