Patient Information

Name *
Name
Address *
Address
Phone *
Phone
Marital Status
Name of Parent/Insurance Policy Holder (if different from above)
Name of Parent/Insurance Policy Holder (if different from above)
Policy Holder Address (If different from above)
Policy Holder Address (If different from above)
Phone (If different from above)
Phone (If different from above)
Insurance Phone Number
Insurance Phone Number
Other Insurance
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. Regardless of any dental insurance a patient may have, the full treatment fees are the responsibility of the patient, not the insurance company or the practice. Full payment of our fees is due at or before the time of treatment. I grant my permission to your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read this form, agree to its terms, and certify I’ve provided all information completely and accurately.
Date
Date