Confidential Information Questionnaire

Marital Status

Emergency Contact Information

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

Request for Confidential Information

As My Dental Care Provider, You May Do the Following With My Permission (If No, Leave Blank)

Contact me at home
Contact me via phone
Contact me at work
Contact me via e-mail
Leave messages on my home voicemail/answering machine
Leave messages on my cell phone voicemail
Leave messages on my work voicemail/ answering machine

Insurance and Financial Information

Insurance Coverage

Patient's Relationship to Subscriber

Secondary Coverage

Patient's Relationship to Subscriber

Release Information

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

Health Care Providers
Insurance Companies


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