Patient Information

Dental Insurance

Assignment And Release

Dental History

Health History

Medications

Patient Information

Date *

SS/HIC/Patient ID #

Last Name *

First Name *

Middle Initial

Address

City

State

Zip

Mobile No *

Home Phone 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?

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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 #:

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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:

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Patient Information

Dental Insurance

Assignment And Release

Dental History

Health History

Medications

Allergies

Services Overview

Cosmetic Dentistry

Root Canals

Dental Implants

Emergency Dentistry

Teeth Whitening

Veneers

Oral Surgery

Gum Disease

703-726-8700 or 703-726-9100