Social Security Number

Email Address

If Student, name of School/College

City

State

Patient or Parent/Guardian Employer

Spouse or Parent/Guardian Name

Employer

Emergency Contact

Whom can we thank for referring you?

Name of Responsible Party for the Account

Relationship to Patient

Email

Driver's License Number

Financial Institution

Employer

Work Phone

Social Security Number/SIN

Name of the Insured

The remaining portion of the form pertains to insurance. If you do not have dental insurance, please submit the form now.

Relationship to Patient

SS#/SIN

Date EmployedName of

Name of Employer

Union or Local Number

Insurance Company

Group Number

Policy/ID #

How much is your deductible?

How much have you used?

Maximum annual benefit

Name of Insured

Please fill this out if you have any additional insurance.

Relationship to Patient

SS#/SIN

Date Employed

Name of Employer

Union or Local #

Insurance Company

Group Number

Policy/ID#

How much is your deductible?

How much have you used?

Maximum Annual Benefit?

Authorization and Release

By typing my name below, I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and /or health practicioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill or services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

PATIENT DENTAL FORMS

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Patient Information - CONFIDENTIAL

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