PATIENT INFORMATION
PATIENT INFORMATION
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|NAME: ________________________________________________________________________________ |
|Last First Middle Initial Preferred Name |
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|SEX: ❑ Male ❑ Female STATUS: ❑ Single ❑ Married ❑ Child ❑ Other |
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|BIRTHDATE: ______--______--______ SOCIAL SECURITY #: ________--_______--_________ |
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|ADDRESS: ____________________________________________________________________________ |
|Street City State Zip |
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|TELEPHONE: Home ________________________ Work __________________________ |
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|PATIENT’S EMPLOYER: ________________________________________________________________ |
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|SPOUSE’S EMPLOYER: _________________________________________________________________ |
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|EMERGENCY CONTACT PERSON: _____________________________ Telephone: ________________ |
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|REFERRED BY (GENERAL DENTIST): ____________________________________________________ |
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OFFICE PAYMENT POLICY
PLEASE READ AND SIGN
The best doctor/patient relationships are maintained when there is complete understanding of the treatment rendered and the fee. Please feel free to discuss the fee at any time. Payment is expected on the day service is rendered. We offer no in-house payment plan; however, we utilize an outside billing agency to assist you with payment arrangements. Please see our front office staff for more information.
Please check the option you prefer:
❑ CASH
❑ PERSONAL CHECK
❑ CREDIT CARD (MasterCard/Visa/American Express/Discover)
❑ AMERICAN GENERAL FINANCE (Must be approved in advance of treatment)
I have read and understand this form: _____________________________________________________
Signature Date
PATIENTS WITH DENTAL INSURANCE: As a convenience to you, we will be glad to assist with filling out insurance forms in order to process a claim to your insurance company on the date of your Root Canal Treatment. Simply fill out the information on the backside. Your insurance company will then send you the reimbursement check directly.
DENTAL INSURANCE
NAME OF INSURED EMPLOYEE: _______________________________________________
INSURED EMPLOYEE’S SOCIAL SECURITY #: _________ --_______--__________
INSURED EMPLOYEE’S EMPLOYER: ___________________________________________
ADDRESS OF EMPLOYEE’S EMPLOYER: ________________________________________
City State
NAME OF INSURANCE COMPANY: _____________________________________________
ADDRESS OF INSURANCE COMPANY: __________________________________________
__________________________________________
GROUP NUMBER: _____________________________________________________________
Blue Cross/Blue Shield Subscriber #: _________________________________________
(Only applies to BC/BS dental patients)
SECONDARY DENTAL INSURANCE:
NAME OF INSURED EMPLOYEE: ________________________________________________
INSURED EMPLOYEE’S SOCIAL SECURITY #: _________ --_______--__________
INSURED EMPLOYEE’S EMPLOYER: ____________________________________________
ADDRESS OF EMPLOYEE’S EMPLOYER: _________________________________________
City State
NAME OF INSURANCE COMPANY: ______________________________________________
ADDRESS OF INSURANCE COMPANY: __________________________________________
__________________________________________
GROUP NUMBER: _____________________________________________________________
Blue Cross/Blue Shield Subscriber #: _________________________________________
(Only applies to BC/BS dental patients)
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