Patient Name: *

Gender: *

Male

Female

Birth Date *

Patient Address: *

City

State

Zip Code

Phone: *

Email: *

Employer:

Occupation:

Name of Spouse or Parent:

Dental Insurance

Insurance Company Name:

Insured's Name:

Date of Birth:

ID or SOC:

Secondary Insurance

Insurance Company Name:

Insured's Name:

Date of Birth:

ID or SOC:

Medical Insurance

Insurance Company Name:

Insured's Name:

Date of Birth:

ID or SOC:

Secondary Insurance

Insurance Company Name:

Insured's Name:

Date of Birth:

ID or SOC:

Person to Contact if Necessary

Contact Person Name: *

Contact Phone: *

Contact Relationship: *

I hereby certify that the above information is true and correct

Sign Date: *

Patient Signature (if over 18) or Parent/Guardian *

Clear

Preferred Pharmacy

Pharmacy:

Address:

City:

ZIP:

Phone Number:

Medications Being Taken Currently

Conclusion

Emergency Contact

First Name: *

Last Name: *

Cellphone Number:

Home Telephone Number:

Accident

Is this related to an accident?

YES

If Yes, what type?

Date of Injury:

Insurance company handling this claim:

Insurance Claim Number:

Name of Attorney/Adjustor:

Attorney/Adjustor Phone:

SIGNATURES

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature: *

Clear

Signing Date: *

Release of Information

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature: *

Clear

Signing Date: *

Fees & Payments

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature: *

Clear

Signing Date: *

Authorization for Service

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment.

Signature: *

Clear

Signing Date: *

Notice of Privacy Practices

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature: *

Clear

Signing Date: *