Patient Full Name *

First Name

Last Name

Residence Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Residence/Cell Phone *

(###)

###

####

Is the patient a minor? (Under 18) *

Yes

No

Insured's Date of Birth

MM

DD

YYYY

Insurance Phone Number

(###)

###

####

Are you covered by a secondary insurance company?

Yes

No

High blood pressure *

Yes

No

Heart murmur or prolapsed valve *

Yes

No

Rheumatic fever or rheumatic heart disease *

Yes

No

Congenital heart disease *

Yes

No

Sinus trouble *

Yes

No

Asthma or hay fever *

Yes

No

Diabetes *

Yes

No

Hepatitis, jaundice or liver disease *

Yes

No

Fainting spells or seizures *

Yes

No

Arthritis *

Yes

No

Artificial joints *

Yes

No

Temporomandibular joint problems (TMJ) *

Yes

No

Cardiovascular disease: heart attack, stroke *

Yes

No

Prosthetic heart valve *

Yes

No

Blood disorder (i.e. Anemia) *

Yes

No

Cosmetic Surgery *

Yes

No

Kidney trouble *

Yes

No

Thyroid *

Yes

No

Tuberculosis *

Yes

No

Persistent cough *

Yes

No

Stomach ulcers *

Yes

No

Cancer *

Yes

No

HIV/AIDS or immunosuppressive disorder *

Yes

No

Are you taking birth control pills or hormones? *

Yes

No

Are you pregnant/nursing? *

Yes

No

Financial Responsibility *

Payment for today’s visit and future visits is due at time of service. We may accept assignment of benefits and will submit your claims as a courtesy to you. If you have insurance, the amount quoted prior to treatment is our best estimate based on what your insurance provider tells us. The balance is your responsibility regardless of your insurance benefit. Your insurance policy is a contract between you and your insurance company. We will do our best to make the most of your insurance benefit. Thank you for understanding our Financial Policy.

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I also understand that I am responsible for any interest (1.5% per month), collection fees (an additional 40% added to balance), reasonable attorney fees and court costs that may occur due to non-compliance of these terms.

Acknowledgement *

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. If necessary, this office may share medical/dental information with your dentist or other specialists to help consult with what treatment may be best for you.