Patient Form -

Patient Information

Patient Name (required)

Date

Email (required)

Gender
MaleFemale

Marital StatusMarriedSingleChildOther

Social Security #:

Birth Date: (required)

Phone:

Address:

Health Information

Date of Last Dental Visit:

Reason for Visit:

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

AIDSAnemiaArthritisArtificial JointsAsthmaBirth ControlBlood DiseaseCancerCongestive Heart FailureDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucoma

GrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureHIVJaundiceKidney DiseaseLiver DiseaseMental DisordersMitral Valve ProlapseNervous DisordersPacemaker

Are you PregnantRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsSulfa AllergyStrokeTuberculosisTumorsUlcersVenereal Disease

Codeine AllergyPenicillin AllergyAllergies

Have you ever had any complications following dental treatment? YesNo

If yes, please explain:

Have you been admitted to a hospital or needed emergency care during the past two years? YesNo

If yes, please explain:

Are you now under the care of a physician?YesNo

If yes, please explain:

Name of Physician:

Phone:

Are you currently taking any medication?YesNo

If yes, please lsit:

To the best of my knowledge, all of the proceeding 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.

Signature of patient, parent or guardian Please sign below with mouse or finger:

Date:

Referral Information

Whom may we thank for referring you to our practice?Another patient, friendAnother patient, relativeDental OfficeYellow PagesNewspaperSchoolWorkOther

Name of person or office referring you to our practice:

Spouse or Responsible Party Information

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

Name:

Gender
MaleFemale

Marital StatusMarriedSingleChildOther

Social Security #:

Birth Date:

Phone:

Address:

Employment Information

The following is for:the patientthe person responsible for payment

Employer Name:

Ocupation:

Address:

Insurance Information

Primary:

Name of insured:

Is insured patient?YesNo

Insured Birth Date:

ID #:

Group #:

Ins Company & Address:

Ins Employers Name:

Address:

Patient`s relationship to insured:SelfSpouseChildOther

Secondary:

Name of insured:

Is insured patient?:YesNo

Insured Birth Date:

ID #:

Group #:

Ins Company & Address:

Ins Employers Name:

Address:

Patient`s relationship to insured:SelfSpouseChildOther

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.

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 23% per year on the unpaid balance will be charged on all accounts exceeding 90 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 and collection 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.

Signature of patient, parent or guardian/ Signature of guarantor of payment/responsible partyPlease sign below with mouse or finger:

Date:

Relationship to Patient:

Burns Family

Dentistry

Burns Family

Dentistry

Burns Family

Dentistry

Patient Information

Health Information

Referral Information

Spouse or Responsible Party Information

Employment Information

Insurance Information

Consent for Services

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Dentist - Deerfield, Il

Burns
Family
Dentistry