Patient Information


MaleFemale
MarriedSingleChildOther


Health Information




AIDS Anemia Arthritis Artificial Joints AsthmaBirth Control Blood Disease Cancer Congestive Heart Failure Diabetes Dizziness EpilepsyExcessive BleedingFainting Glaucoma

Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure HIV Jaundice Kidney Disease Liver Disease Mental Disorders Mitral Valve Prolapse Nervous Disorders Pacemaker

Are you Pregnant Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus ProblemsStomach Problems Sulfa Allergy Stroke Tuberculosis TumorsUlcers Venereal Disease

Codeine Allergy Penicillin Allergy

YesNo

YesNo

YesNo

YesNo

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Referral Information

Another patient, friendAnother patient, relativeDental OfficeYellow PagesNewspaperSchoolWorkOther

Spouse or Responsible Party Information

the patient's spousethe person responsible for payment

MaleFemale
MarriedSingleChildOther


Employment Information

the patientthe person responsible for payment

Insurance Information

YesNo

SelfSpouseChildOther


YesNo

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.

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