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Patient Information

Date *

SS/HIC/Patient ID #

Last Name *

First Name *

Middle Initial

Address *

City *

State *

Zip *

Home Phone No *

Mobile No *

Emergency Contact Name *

Emergency Contact No *

E-mail *

Sex

M F

Birth Date *

Age

Civil Status *

Patient Employer / School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse's Birthdate

Spouse's SS#

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account? *

Relationship to Patient *

Insurance Co. *

Group #:

Is patient covered by additional insurance? *

Yes No

Subscriber's Name:

BirthDate:

SS#:

Relationship to Patient:

Insurance Co.:

Group #:

Assignment And Release

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services.

Date:

Relationship to Patient: