Patient Information


       
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Insurance Information

Primary Insured (If no insurance, complete for responsible party.)



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Secondary Insured



You will be asked to provide this information at our office.


Emergency Contact



Method of Payment

Does responsible party currently have an account with this office?
Payment in full is due at each appointment. Please select your payment method.


Service Charge

I understand that if I do not pay the entire new balance of my account within the agreed upon number of days of the monthly billing date, a service charge will be applied to the account for the current monthly billing period. In the case of default payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.

Authorization

I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals by any method, including electronic transfer.

Has any member of your family ever been treated in our office?


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