PATIENT

RESPONSIBLE PARTY (If same as above, please skip)

EMPLOYMENT

(Office use only)

REFERENCES

PERSON TO CONTACT FOR EMERGENCY:

GETTING TO KNOW YOU Do you have family members who may

Do you have family members who may need dental care? If so, please list name & relationship (son, daughter, husband) How did you hear about our office? (Circle one)

INSURANCE / DENT AL PLAN

INSURANCE / DENTAL PLAN

1. I certify that the information provided is accurate and will be relied upon for granting credit and providing dental services. I understand that I am financially responsible for the charges not covered by or paid by my insurance for whatever reason.
2. By signing below, I authorize that you may verify and exchange information on me and any additional applicants, including requiring reports from credit reporting agencies.
3. I authorize payment directly to the dentist of any group insurance benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by this authorization. I authorize release of any information relating to any dental claim or claims.
4. I understand that this dental practice is owned and operated by an independent dentist. I acknowledge that each dentist is individually responsible for the dental care provided to me and no other dentist or corporate entity is responsible for my dental treatment.