Getting To Know You As Our Patient

Kindly fill out the form below so we can serve you better. Thank you

    Patient's Information

    Insurance Information

    Responsible Party's Information

    Spouse's Details

    How did you hear about our Office?




    Terms & Conditions

    This office depends upon reimbursement from the patient for the costs incurred in their case. The financial responsibility of each patient must be determined before treatment. As a condition of treatment by this office, I understand financial arrangements must be made in advance. All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for at the time the services are performed. I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment. If I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental office cannot render services on the assumption that charges will be paid by an insurance company

    Assignment of Insurance: I hereby authorize releases of any information needed and also authorize my insurance company to pay directly to this Office benefits accruing to me under my policy. I understand that the fee estimate listed for this dental care can only be extended for a period of 90 days from the date of the patient’s examination. I also understand that in order to collect my debt, my credit history may be checked through the use of my Social Security Number or any other information I have given you. I agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney’s fees. I grant my permission to you, or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions and agree to their content


    Patient Dental Health

    Patient Medical History

    Do you or have you had any of the following?


    Are you allergic to any of the following?

    Please list all medications you are currently taking:

    In the event of an emergency please contact

    Initial medical/dental health reviewed by:

    Periodic medical/dental health reviewed by: