Patient Information

Patient Name

years

Dental Insurance

I certify that I, and/or my dependent(s), have insurancecoverage with and assign dirrectly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Phone numbers

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Dental History

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Health History

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Women

Medications

Updates (To be filled in at future appointments)