Patient Information

Please allow 5 - 10 minutes to complete the form. We recommend you use this online form, but if you prefer to print it out, please click here.

* = required

Address

 

Contact Information

Insurance Information

By providing the information below, we can review your insurance plan before you arrive to maximize your benefits.

 

Medical History

 
 
 
 

Do you have or have you ever had any of the following

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Agreement & Acknowledgment

 

I, the undersigned hereby authorize the Doctor to take radiographs, study models, photographs, records or any other diagnostic aids he/she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent the Doctor to employ any such assistance as he/she deems appropriate under the law. I further authorize the release of diagnosis, radiographs, patient records, treatments or examinations rendered: to my insurance company, consulting professionals and others I approve.

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney's and collection fees. Reservations require a great deal of setup and preparation tailored to you and your treatment. Last minute cancellations and missed reservations will be charged $50.00 per half hour scheduled. To avoid this charge, contact our office within 48 hours of your reservation. We do understand, on occasion, last minute things occur. If we both take our commitment to each other seriously, these issues are often avoidable.

I certify that the information given is correct and current. I understand it is my responsibility to notify Terry L. Isom DMD, PC of any changes. I understand if I withhold information regarding allergies, medical conditions, medications, or supplements; I agree not to hold Terry L. Isom DMD, PC or its employees liable in the event of death or injury. I am aware that it is my responsibility to read and understand my own dental insurance policy, including benefits, limitations and exclusions. I understand that filing of insurance claims is my responsibility and may be provided as a service to me and that any agreement for dental coverage is between my insurance company and myself. I understand that an estimated portion is due at time of service and is estimated according to expected coverage, which may not be disclosed nor guaranteed by my insurance company. I understand my portion may be more if my insurance company does not pay the anticipated amount. I also understand that services are rendered independent of insurance reimbursement. Reservations require payment in full unless approved arrangements have been made. Returned checks will be charged $30.

We accept - Visa, Master Card, and Discover; Financing is available OAC.

Legal binding signature. Please type your full legal name.