Adult Patient Form | Samra Orthodontics

ADULT PATIENT FORM

DATE:

WELCOME TO OUR PRACTICE

PATIENT INFORMATION

Patient’s Name * FIRST

Middle

Last

Address: STREET

APT

CITY

STATE

ZIP

Home Phone

Cell Phone

Birthdate

Age

Patient’s Family Dentist

Patient’s Family Physician

Referred By

Employer

Occupation

Social Security No.

Work Phone

Emergency Contact

Phone

Has a family member ever been a patient in this office?

If Yes, whom?

INSURANCE INFORMATION

Insured’s Name

Insured’s Birthdate

Insured’s Social Security No.

Insured’s Employer

Insurance Company

Group No.

SECONDARY INSURANCE

Insured’s Name

Insured’s Birthdate

Insured’s Social Security No.

Insured’s Employer

Insurance Company

Group No.

CONSENT TO ORTHODONTIC RECORDS

I hereby grant authority to the team at Samra Orthodontics to take orthodontic records which consist of a panoramic radiograph, cephalometric radiograph, digital study models, and intraoral/extraoral pictures. Records are needed for the orthodontist to accurately provide a diagnosis and treatment recommendations. I understand that more detailed information will follow for specific procedures prior to treatment being rendered.

****Please notify our team if you suspect you might be pregnant prior to taking radiographs****

INSURANCE ASSIGNMENT OF BENEFITS

I hereby assign Samra Orthodontics all dental benefits to which I am entitled. I hereby authorize and direct my insurance carriers to issue payments directly to Samra Orthodontics for dental services rendered to myself or my dependent regardless of my insurance benefits. Samra Orthodontics will provide an estimate of insurance coverage upon request. I understand that Samra Orthodontics is not responsible for inaccurate estimates. Payments of claims are not guaranteed by any insurance and are based on eligibility and policy coverage at the time a claim is submitted. I understand that I am responsible for any amount not covered by insurance and I agree to pay any balance amount, in a timely manner.

Date:

Patient Name:

Patient Signature:

209.478.4666