LKN New Patient Adult Form | Lake Norman Orthodontics

PRIMARY DENTAL INSURANCE ONLY

Ortho coverage?

If “Yes” complete below

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local, or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

SS#:

Policy Owner’s Employer:

SECONDARY DENTAL INSURANCE ONLY

Ortho coverage?

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local, or Policy #):

Policy Owner’s Name:

Relationship to Patient:

Policy Owner’s Birthdate:

SS#:

Policy Owner’s Employer:

PATIENT AUTHORIZATION – PLEASE SIGN BELOW

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature:

Date:

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

Signature:

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

Date:

Adult Information Form

Lake Norman

Orthodontics

PERSONAL INFORMATION

Spouse Information

MEDICAL HISTORY

DENTAL HISTORY

PRIMARY DENTAL INSURANCE ONLY

SECONDARY DENTAL INSURANCE ONLY

PATIENT AUTHORIZATION – PLEASE SIGN BELOW