Document Downloads & Binding Arbitration Information

(INSERT OFFICE NAME HERE)

Patient Information

Patient Name___________________________________________Account #_______________

First Middle Initial Last (office use only)

Address____________________________ _ City ____________________________________

State________________________________ ZIP____________ Home Phone______________

Employer Phone ______________________ Birthdate__________________ _______________

E-mail address _______________________ Social Security Number_____________________

Employer Name and Address______________________________________________________

Marital Status: Married Single Divorced Widowed Patient Gender: M F

Spouse ______________________________ Spouse Birth Date _________________________

Spouse Employer _______________________Spouse SSN______________________________

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Responsible Party (if different from above)

Name________________________________ Relationship______________________________

Birthdate _____________________________ SSN____________________________________

Employer ____________________________ Employer Phone___________________________
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Dental Insurance Information

Policy Holder’s Name__________________________________ Phone____________________

Social Security Number ________________________________ Birthdate _________________

Employer_____________________________ Employer Phone___________________________

Insurance _____________________________ Policy Number____________________________

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How did you hear about our office? _______________________________________________

Reason for today’s visit: toothache swelling lost filling accident

denture s routine check up other_________________________

Medical Information

Emergency Contact (not living with you)__________________________________________________ Name Phone Relationship

Medications currently taking_____________________________________________________________
____________________________________________________________________________________

*HAS ANY DOCTOR TOLD YOU THAT YOU NEED TO TAKE AN ANTIBIOTIC BEFORE DENTAL PROCEDURES DUE TO A MEDICAL CONDITION?

Please circle: YES NO

Allergies you have (Circle):

Anesthetic Aspirin Codeine Keflex Motrin

Penicillin Sulfa Tetanus Tylenol Other___________

Please check all that apply and fill in dates:

Please read carefully

(INSERT NAME) requires payment at time service is rendered. We accept all major credit cards and debit cards. Deferred payment is available through an interest free account with qualified credit. Payment by check is accepted, however in the unlikely event your check is returned, we reserve the right to re-present the item electronically, plus the state allowed processing fee.

I authorize payment of group insurance benefits, otherwise payable to me, directly to (INSERT NAME). My signature is also a file signature for dental insurance. I understand any outstanding balance my insurance does not pay will be my responsibility.

I authorize (INSERT NAME) to verify my past and present credit references.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. We are required by federal and state law to maintain the privacy of your health information. We may use or disclose your health information for such reasons listed below: Another health care provider treating you, to obtain payment for services rendered, in connection with our healthcare operations, in reasonably suspected abuse or neglect cases, national security and for appointment reminders. You have the right to access, amend, request a disclosure accounting, and request alternative communications regarding your health information. All must be in writing. You are entitled to receive this notice in written form.

I agree that any dispute about the reasonableness or computation of fees, or any claim of negligent or intentional acts or omissions in the rendering of professional services by any member of (INSERT NAME) staff or our doctors, shall be submitted to binding arbitration. It is understood by both doctor and patient that by agreeing to submit all claims or assertions that either patient or doctor may have against the other, arising out of this agreement, all disputes shall be resolved through arbitration.

(INSERT NAME) requires advance notice if an appointment has to be cancelled or rescheduled. Please be advised after three missed appointments, (INSERT NAME) will not reserve appointments in advance.

Signed___________________________________________________________________

Date______________________________________