480-405-0300
Patients Legal Name (Last, First, MI)
Date of Birth
Sex
Social Security #
Preferred Name
Home Phone #
Street Address
City
State
Zip
Email Address
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
Person We May Contact In Case of An Emergency (Other Than Your Family Home)
Name
Relationship
Cell Phone #
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 Company Name
Insurance Phone #
Subscriber's Name
Subscriber's Birthday
Subscriber's SSN #/ID #
Group Program Number
Employer (If Different From Above)
Employer's Address
You May Discuss My Healthcare With (If No, Leave Blank)
Others
Do You Prefer a Confirmation Call
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
