Patient Information Date / Time Name First Middle Last Gender — Select — Male Female NA Marital Status — Select — Married Single Child Age Social Security # Birthdate Home Phone Work Phone Cell Phone Email Address Driver's License Number and State Street Address City, State Zip Code Date of Last Dental Visit and Reason for This Visit Have you ever experienced any of the following conditions? Please check all that apply. AIDS Allergies Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Hay Fever Head Injuries Heart Disease Hepatitis A Hepatitis B Hepatitis C Hepatitis Other High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Pregnancy Current Radiation Treatment Respiratory Problems Rhematic Fever Rheumatism Sinus Problems Stomach Problems Stroke Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy Please list any others that apply. Have you experienced any complications with dental treatment? Have you been admitted to a hospital or needed emergency care during the past two years? Are you currently under the care of a physician? Please explain. Name and phone number of physician. To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. Sign and Date Whom may we thank for referring you to our practice? Another patient/friend Another patient/relative Dental Office Yellow Pages Newspaper Radio Internet School Work Other Name of Person Referring First Middle Last Spouse or Responsible Party Information Name of Responsible Party First Middle Last Gender Male Female Marital Status Married Single Child Social Security # Responsible Party Birth Date of Responsible Party Home Phone of Responsible Party Work Phone Street Address of Responsible Party City, State and Zip Code It is not easy for an office to become familiar with the details of every dental plan it encounters. It is the responsibility of the patient to know what is covered and excluded from his or her own dental plan. We will do our best to inform you of what we know, but ultimately you acknowledge that your are responsible for any and all charges not covered. Please enter your name and date below to acknowledge that you consent and understand. Name of Insured First Middle Last Is insured a patient? Yes No Insured Birth Date Insurance ID# Insurance Group # Insured Street Address City, State, and Zip Code Insured Employer Name Employer Street Address Insurance Plan Name and Address City, State, and Zip Code Patient's Relationship to Insured Self Spouse Child Divorce Decree Insurance Plan Name and Address Secondary Insurance Information Name of Insured First Middle Last Insured Birth Date Is insured a patient? Yes No Insurance ID# Insurance Group # Insured Street Address City, State, and Zip Code Insured Employer Name Employer Street Address City, State, and Zip Code Patient's Relationship to Insured Self Spouse Child Divorce Decree As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement fromt eh 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 service performed without previous financial arrangements must be paid for in cash at the time services are performed. Patients hwo 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 insruance companies and will credit any such collections to the patient's account. However, this dental office canno render services on the assumption that our charges will be paid by an insurance company. A service charge of 2% per month (24% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days unless previous written financial arrangements have been made. I understand that the fee estimate listed ofr 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 whithin five (5 ) days of billing if credit shal bee 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 the payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a wiaver of any further term or condition and I further agree to pay all costs of collection including a 50% collection fee, attorney fees and court costs. 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. My name and date below act as my signature and are binding of my own free will.