• PATIENT INFORMATION - MINOR
  • THIS INFORMATION IS NECESSARY FOR OUR FILES AND WILL BE CONSIDERED CONFIDENTIAL

  • Patient's name
  • Birthdate
  • Residence address
  • School
  • Grade
  • Phone no.
  • Father's name
  • Birthdate
  • Driver's license no.
  • Social security no.
  • Res. phone
  • Employed by
  • Occupation
  • Business address
  • Bus. phone
  • Mother's name
  • Birthdate
  • Soc.sec.no.
  • Employed by
  • Occupation
  • Business address
  • Bus. phone
  • Name of nearest relative not living with you
  • Relationship
  • Complete address
  • Res. phone
  • Name of physician
  • Phone
  • Purpose of appointment
  • Whom may we thank for referring you?
  • Person responsible for this account
  • Relationship
  • Address
  • Phone
  • Preference of payment;
  • CASH CHECK CREDIT CARD
  • Bank
  • Account no.
  • Insurance company
  • Group no.
  • Insured person's name
  • Employee no.
  • Secondary insurance co.
  • Group no.
  • Insured person's name
  • Employee no.
  • CONSENT FOR TREATMENT: I HEREBY GRANT AUTHORITY TO THE DENTIST (S) IN CHARGE OF THE CARE OF THE PATIENT WHOSE NAME APPEARS ON THIS FORM, TO ADMINISTER SUCH ANESTHETICS, ANALGESICS, SEDATIVES, OR NITROUS OXIDE SEDATION; AND TO PERFORM SUCH OPERATIONS AS MAY BE DEEMED NECESSARY OR ADVISABLE IN THE DIAGNOSIS AND TREATMENT OF THIS PATIENT. I HAVE BEEN INFORMED OF ALL POSSIBLE COMPLICATIONS OF THE PROCEDURES, ANESTHETICS AND / OR DRUGS.
  • Signature
  • Date
  • INSURANCE AUTHORIZATION
    I AUTHORIZE RELEASE OF INFORMATION TO ALL MY INSURANCE CARRIERS
    I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR
    I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL
  • Signature
  • Date
  • FINANCIAL POLICY
  • Our financial policy is payment is due at the time of treatment. We will inform you of the fee of your recommended treatment at the time it is diagnosed. And offer financing options.
    • We believe these options will prove to be a service to you and your family.
  1. A 5% reduction in your fee if you pay for services in advance of the treatment being initiated.
  2. Payment by appointment. This option allows you to spread out the payments according to your treatment plan.
  3. Payment with Mastercard, Visa, Discover and American Express. This will allow you to comfortably budget your monthly payments.
  4. Insurance on assignment. As a service to you, we will continue to file your insurance and accept assignment of benefit from your insurance company. This will help reduce your immediate 'out of pocket' expenditures - only the estimated private pay monies will be due at the time of treatment
  5. Long term or extended financing will be offered through Care Credit. This is our new financial partner that will allow our patients to invest in their oral health with small monthly payments over an extended period of time.
  6. A finance charge of 18% may be added to outstanding balances.
  • I understand that all responsibility for payment for dental services provided in this office for my dependents or myself is mine, due and payable at the time services are rendered.
  • Signature
  • Date

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