Information

Confidential Information Questionnaire

Patients Legal Name (Last, First, MI)

Date of Birth

Sex

Social Security #

Preferred Name

Home Phone #

Street Address

City

State

Zip

Email Address

Marital Status

Patient's/Guardian's Employer

Occupation

Work Address (Street, Apt#, City, State, Zip)

Work Phone #

Spouse's Name (Last, First, MI)

Spouse's Work Phone #

Spouse's Employer

Who Can We Thank For Referring You to Our Office?

Other Family Members That Are Patients Here

Emergency Contact Information

Person We May Contact In Case of An Emergency (Other Than Your Family Home)

Name

Relationship

Home Phone #

Work Phone #

Cell Phone #

Request for Confidential Information

As My Dental Care Provider, You May Do the Following With My Permission (If No, Leave Blank)
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Contact me at home
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Contact me via phone
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Contact me at work
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Contact me via e-mail
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Leave messages on my home voicemail/answering machine
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Leave messages on my cell phone voicemail
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Leave messages on my work voicemail/ answering machine
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Insurance and Financial Information

Insurance Coverage

Insurance Company Name

Insurance Group Name

Insurance Phone #

Subscriber's Name

Patient's Relationship to Subscriber

Subscriber's Birthday

Subscriber's SSN #/ID #

Group Program Number

Employer (If Different From Above)

Employer's Address

Secondary Coverage

Insurance Company Name

Insurance Group Name

Insurance Phone #

Subscriber's Name

Patient's Relationship to Subscriber

Subscriber's Birthday

Subscriber's SSN #/ID #

Group Program Number

Employer (If Different From Above)

Employer's Address

Release Information

You May Discuss My Healthcare With (If No, Leave Blank)

Health Care Providers
Insurance Companies

Others

Others

Confirmations

Do You Prefer a Confirmation Call

Assignment & Release

I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations and/or presentations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved

E-Signature

Date Signed