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EPSON STYLUS CX3200
2011-08-15T16:37:22-07:00
Microsoft Office Document Scanning 12.0.6423.1000
mgavrila
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P Rr 2 ) 6 , , , , Microsoft Office Document Scanning 12.0.6423.1000 2011:08:15 16:37:22 mgavrila y L
(This information is necessary for our files and will be considered CONFIDENTIAL)
Date
Patient’s Name Age Patient’s Birthday Male Female
LAST FIRST INITIAL
If patient is a minor, give name of parent or legal guardian Relationship
Residence Address For how long? Own Rent
STREET Girl’ ZIP
Patient is: lJ Married Single Divorced Separated l Widowed L1 Minor Email
Driver’s license No. Social Security No. Res. Phone
Bank Account No. How long? Cell Phone
Employed by How long? Occupation
Business Address Bus. Phone
STREET CITY ZIP
Spouse’s Name Driver’s license No. Soc. Sec. No.
Employed by How long? Occupation
Business Address Bus. Phone
STRtzET ZIP
Name of nearest relative not living with you Relationship
Complete Address Res. Phone
STREET Girl’ ZIP I have no physician
Name of Physician
ADDRESS CDV TELEPHONE
Former Dentist
ADDRESS CITY TELEPHONE
Why are you changing dentists?
Do you wish to speak to the
Purpose of Appointment doctor privately? L Yes No
Is this office visit for Emergency Dental Care? L Yes No If yes, explain:
School Children Attend Whom may we thank for referring you?
Person responsible for this account Relationship
TELEPHONE
Address
STREET CITY ZIP CELL PHONE
PREFERENCE OF PAYMENT: Cash on day of treatment LI Visa No.
EXPIRATION DATE
LI StateAidNo. LI MastercardNo.
EXPIRATiON DATE
Name of insurance company (primary insurance)
INSURED PERSONS NAME BIRTHOATE RELATIONSHIP SOCIAL SECURITY NO.
NAME OF GROUP DENTAL PLAN GROUP NO. PLAN NO. NAME OF UNION LOCAL
Name of insurance company (secondary insurance)
INSURED PERSONS NAME BIRTHDATE RELATiONSHIP SOCIAL SECURITY NO.
NAME OF GROUP DENTAL PLAN GROUP NO PLAN NO. NAME OF UNION LOCAL
I . — :ss ... .
As a condition of treatment by this office, I understand 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 service performed without prior financial arrangements, must be paid for in cash at the time services are performed.
I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment of all dental services. If I carry insurance, I understand
that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental
office cannot render services on the assumption that charges will be paid by an insurance company.
Assignment of Insurance: I hereby authorize my insurance company to pay directly to my dentist benefits accruing to me under my policy.
A service charge of 11/2% per month (18% per annum) (but in no event more than the maximum rate permissible under state law) will be charged on the unpaid principal balance
on all accounts not paid within 60 days of treatment date.
I understand that the fee estimate listed for this dental case can only be extended for a period of six months from the date of the patient’s examination.
In consideration of the professional services rendered to me, or at my request, by the Doctor and/or his staff, 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 billed unless objected to by me, in writing, within the time for payment thereof. Additionally, I agree that a waiver for any breach of any term or condition
hereunder shall not constitute a waiver of any further term or condition. I further agree that in the event that either this office or I institute any legal proceedings with respect
to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney’s and/or
collection fees.
I grant my permission to you, or your assigns, 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 agree to their content:
Signed...
PLE4SE COMPLETE BOTH SIDES (PATIENT INFORMATION FORM 1OD-6 / REvOS/09 / 50009 DENRAM
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