New Patients

Patient Name *

First

Last

Date of Birth (mm/dd/yy) *

Age *

Sex *

Male
Female

Social Security Number *

Street Address *

City *

State *

Zip *

Home Telephone (Including Area Code) *

Cell Phone (Including Area Code) *

Work Phone (Including Area Code) *

Extension

Dentist Name *

First

Last

Physician Name *

First

Last

Referred By *

First

Last

Parent Name (if patient is a minor)

First

Last

Parent Address

Parent Social

Student *

Full Time
Part Time
Not

School Name

Marital Status *

Employed *

Full Time
Part Time
Retired
Not

Employer Name

First

Last

Employer Address

Emergency Contact

First

Last

Emergency Phone Number

Does the Patient Have Medical Insurance? *

Yes
No (Self-Pay)

Medical Insurance Co.

ID Number

Medical Insurance Co. Address

Medical Insurance Co. Phone Number

Group Name

Subscriber Name

First

Last

Subscriber Address (if different from patient)

Phone Numbers (if different from patient)

Date of Birth

Patient Relationship to Subscriber

Self
Spouse
Child
Other

Are You Pregnant?

Yes
No

If Yes, Estimated Delivery Date

Does the Patient Have Dental Insurance? *

Yes
No (Self-Pay)

Dental Insurance Co.

Dental Insurance Co. Address

Dental Insurance Co. Phone Number

ID Number (Dental)

Group Name (Dental)

Subscriber Name (Dental)

First

Last

Dental Subscriber Address (if different from patient)

Dental Phone Numbers (if different from patient)

Date of Birth (Dental)

Patient Relationship to Subscriber (Dental)

Self
Spouse
Child
Other

Are You Pregnant? (Dental)

Yes
No

If Yes, Estimated Delivery Date (Dental )

Fee and Payment: Signature of Patient (Parent or Gradian if Minor) *

Please remember that insurance is not a substitute for payment. Some companies pay fixed allowances for a certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company. This signature on file is authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the doctor named on the benefits otherwise payable to me. There will be $50.00 charge for any returned checks. If there is a returned check, it must be paid in full, along with the $50.00 returned check fee in cash within 24 hours or it will be turned over to the Sheriff's Department for collection.

Date *

Authorization: Signature of Patient (Parent or Gradian if Minor) *

I authorize my surgeon and his/her designated staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment. This signature on file is authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the doctor named on the benefits otherwise payable to me. There will be $50.00 charge for any returned checks. If there is a returned check, it must be paid in full, along with the $50.00 returned check fee in cash within 24 hours or it will be turned over to the Sheriff's Department for collection.

Date (Authorization) *

Authorization for Release of Medical/Dental Records: Signature of Patient (Parent or Gradian if Minor) *

I hereby request and authorize the release of all information regarding any physical and mental condition, as revealed by your observation or treatment, past, present or future. This includes photocopies of medical and/or dental histories, x-ray findings, diagnosis, treatment, prognosis and financial records.

Date (Medical Records) *

Acknowledgement of Receipt of Privacy Notice *

Signature of Patient or Personal Representative

Date (Acknowledgement) *

Personal Representative's relationship to Patient *

Locations and Contacts