Patient Information Form

This form is for any new patient or existing patient.

If sent this form please complete in its entirety.

We also need this form completed to update existing accounts every 6 months.

Appointment For

New Patient Exam/ Consult

Check-Up

Emergency

Treatment

Adult/ Parent/ Legal Guardian Name

First Name

Last Name

Adult/ Parent/ Legal Guardian Date of Birth

YYYY

Your Email

Your Phone #

(###)

###

####

Your Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Adult/ Parent/ Legal Guardian Name (2)

Complete if adding another adult.

First Name

Last Name

Adult/ Parent/ Legal Guardian Date of Birth (2)

Complete if adding another adult.

YYYY

Child Name (1)

First Name

Last Name

Child Date of Birth (1)

YYYY

Child Name (2)

First Name

Last Name

Child Date of Birth (2)

YYYY

Child Name (3)

First Name

Last Name

Child Date of Birth (3)

YYYY

Medical Health History

List past medical conditions, illnesses, and current medications. Input NONE if none.

Current Medications

Please list any known drug allergies. Input NKDA if none.

Do you have a PPO Insurance Plan? (If yes, all the insurance questions below must be completely filled out.)

Yes

Insurance Company

Insurance Subscriber Name

First Name

Last Name

Insurance Subscriber Date of Birth

YYYY

Insurance ID Number

(Input Subscriber SSN for Metlife)

Credit Card Number

Credit Card Expiration Date. Format MM/YY

Credit Card Security Code

Billing Zip Code

Credit Card Authorization

Providing credit card information authorizes payment for services. A 3.5% processing fee applies to all credit card transactions. Thank you.

I Acknowledge

Appointment Change Policy

There is a fee of $125 for all Appointment changes within 48 hours of scheduled appointments.

I Acknowledge

Out-of-Network Practice Acknowledgment

We are Out-of-Network with all insurance companies. Most PPO dental insurance plans include out-of-network benefits, generally providing 50-100% coverage. While we may attempt to verify your insurance benefits based on the information you provide, please note that any details received from your insurance company are not a guarantee of benefits. We recommend reaching out to your insurance provider to confirm the Out-of-Network benefits of your plan and to inquire about the percentage of coverage for services rendered. To streamline the payment process, we collect full payment at the time of the visit, aligning with the common practice for out-of-network specialists. Following the payment, we will supply you with a receipt showing services rendered and your payment. You can then submit this receipt to your insurance company, and they will reimburse you directly based on the terms of your contract with them.

I Acknowledge

Additional Information