Chart #: __________

FOR OFFICE USE ONLY

Patient Information- (Front and Back)

Patient Name: _________________________________________________________ Date: _______________

Last First MI

Male Female Married Single Child Other _____________

Social Security #: ________________________________ Birth Date: _________________________________

Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call: _____________

Email address____________________________________________________________________________________________________

Preferred appointment times: Morning Afternoon Evening Any Time M T W T F S

Address: __________________________________________________________________________________

Street Apartment #

__________________________________________________________________________________

City State Zip Code

Health Information

Date of Last Dental Visit: __________________ Reason for this visit: ___________________________________

Height: ______________ Weight: _____________Use of Botox or Restalyn ___________________________________

Have you ever had any of the following? Please check those that apply:

AIDS

Allergies __________

__________

Anemia

Arthritis

Artificial Joints

Asthma

Blood Disease

Cancer

Diabetes

Dizziness

Epilepsy

Excessive Bleeding

Fainting

Glaucoma

Growths

Hay Fever

Head Injuries

Heart Disease

Heart Murmur

Hepatitis

High Blood Pressure

Jaundice

Kidney Disease

Liver Disease

Mental Disorders

Nervous Disorders

Pacemaker

Pregnancy

Due date:_________

Radiation Treatment

Respiratory Problems

Rheumatic Fever

Rheumatism

Sinus Problems

Stomach Problems

Stroke

Tuberculosis

Tumors

Ulcers

Venereal Disease

Codeine Allergy

Penicillin Allergy

OTHER:

______________

_________________

· Have you ever had any complications following dental treatment? Yes No

If yes, please explain: _______________________________________________________________________

· Have you been admitted to a hospital or needed emergency care during the past two years? Yes No

If yes, please explain: ______________________________________________________________________

· Are you now under the care of a physician? Yes No. Are you taking any medication either prescribed or over the counter

If yes, please explain: ______________________________________________________________________

· Name of Physician: _______________________________________________ Phone: ___________________

· Do you have any health problems that need further clarification? Yes No

If yes, please explain: ______________________________________________________________________

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

_________________________________________________________________ Date: ___________________

Signature of patient, parent or guardian

Referral Information

Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative

Dental Office Yellow Pages Newspaper School Work Other__________________

Name of person or office referring you to our practice: ______________________________________________

Spouse or Responsible Party Information

The following is for: the patient's spouse the person responsible for payment

Name:

Male Female Married Single Child Other

Social Security #: ________________________________ Birth Date:

Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call:

Address:

Street Apartment #

City State Zip Code

Employment Information

The following is for: the patient the person responsible for payment

Employer Name: Occupation:

Address:

Street City State Zip Code

Insurance Information

Primary

Name of Insured: _______________________________________________ Is insured a patient? Yes No

Last First MI

Insured's Birth Date: _________________ ID #: _____________________ Group #:

Insured's Address:

Street City State Zip Code

Insured's Employer Name:

Address:

Street City State Zip Code

Patient's relationship to insured: Self Spouse Child Other___________________

Insurance Plan Name and Address:

Secondary

Name of Insured: _______________________________________________ Is insured a patient? Yes No

Last First MI

Insured's Birth Date: _________________ ID #: _____________________ Group #:

Insured's Address:

Street City State Zip Code

Insured's Employer Name:

Address:

Street City State Zip Code

Patient's relationship to insured: Self Spouse Child Other___________________

Insurance Plan Name and Address:

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Broken and missed appointments will be assessed a fee.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

____________________________________________________ Date: _____________ Relationship to Patient:

Signature of patient, parent or guardian

____________________________________________________ Date: _____________ Relationship to Patient:

Signature of guarantor of payment/responsible party