Confidential Information Questionnaire

Patient
Last Name
Patient
Fist Name
Patient
Middle Name
Preferred Name
Date of Birth
Gender
Male  Female
Home Phone
Mobile Phone
Email
Patient's Address:
Marital Status
S   D  W
Patient/Guardian Employer
Occupation
Work Address
Work Phone:
 
 
Spouse
Last Name
Spouse
Fist Name
Spouse
Middle Name
 
Spouse
Employer
Spouse 
Occupation
Spouse
Work Address
Spouse
Work Phone
 
  
Other Family Members Who Are Patients Here
Who Can We Thank For Referring You To Our Office?
  

EMERGENCY CONTACT INFORMATION

PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)

Emergency Contact Name
Emergency Contact Relationship
Home Phone #
Work Phone #
Mobile Phone
     

PHARMACY

Pharmacy Name
Pharmacy Phone Number
  

INSURANCE AND FINANCIAL INFORMATION

Have insurance coverage? Yes  No
Insurance Company Name
Insurance Company Address
Insurance Company Phone
Subscriber's Name
Patient's Relationship to Subscriber
Subscriber's Birthday
Group Program Number
Employer (if different from above)
Employer's Address
 
Have secodary insurance coverage? Yes  No
Insurance Company Name
Insurance Company Address
Insurance Company Phone
Subscriber's Name
Patient's Relationship to Subscriber
Subscriber's Birthday
Group Program Number
Employer (if different from above)
Employer's Address
          

ASSIGNMENT AND RELEASE

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

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

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

 
SIGNATURE PATIENT/GUARDIAN DATE