Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.
* Indicates required field .

Patient First Name:    Last:    M.I.:     Preferred Name:
Title: (Mr, Ms, Mrs, etc.)            Birth Date:     Prev. Visit Date: 
Email Address:  
Phone:  Home    Work - ext   Mobile   Best time to call: 
Address:    Address 2 
City:    State:    Zip:
Whom may we thank for referring you to our practice?
Dental Office
Yellow Pages


Other - If other Name of person, office, or other source referring you to our practice.

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that preserves your overall health and well-being.
Would you consider yourself to be in fairly good health? 
Within the past year, have there been any changes in your general health? 
What is the date (or approximate date) of your last medical exam? 
Your Primary Care Physician's name, address, & phone number:

Please mark any of the following to indicate Yes in response to the question:
Have you ever had complications following dental treatment?
Are you currently under the care of a physician due to a specific condition?
Have you been hospitalized within the last 5 years due to a surgery or illness?
Are you currently taking an prescription or non-prescription medications?
Do you use tobacco (smoking or chewing)?
Do you require the use of corrective lenses (contacts or glasses)?
Do you have any other conditions, diseases, etc., not listed above that we should be aware of?
If any of the previous questions are marked, please explain:
Please mark those that apply:
Artificial Joints

Dry Mouth
Excessive Bleeding

Heart Disease
Heart Murmur

Mitral Valve Prolapse

Rheumatic Fever
Take Blood Thinner
If any of the above boxes checked need further explanation, please provide:
WOMEN ONLY: Are you pregnant?   

Name of Insured (last - First - MI)

Is insured a patient?   

Insured's Birth Date:        ID#:      Group #:

Insured Employer's Name: 

Patients relationship to insured:     If Other: 

Insurance Plan Name and Address:

* I have reviewed the previous insurance information.  I authorize release of any information relating to this claim.  I understand that I am responsible for all costs of dental treatment.  I hereby authorize payment of the dental benefits otherwise payable to me directly.

Secondary Name of Insured (last - First - MI)

Is insured a patient?   

Insured's Birth Date:        ID#:      Group #:

Insured Employer's Name: 

Patients relationship to insured:     If Other: 

Insurance Plan Name and Address:


As a condition of your treatment by this office, financial arrangements must be made in advance.  The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services.  This office  will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account.  However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand the the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee at the time said services are rendered, or within five (5) days of billing if credit shall be extended.  I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof.  I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.  I have received a copy of this office's Notice of Privacy Practices.

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 of treatment and payment and agree to their content.  I have read the office's Notice of Privacy Practices.

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