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Our Dental Services
Insurance & Financial
Print Patient Form
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Your registration has been sent to our office.
Spouse's Name (Parent or Guardian if Minor)
Other family members living at same address
Person Providing Insurance
Insured Birth date
Dental Insurance Company Name
Insured Employer's Name
Insurance Co Address
Ins Co Phone #
As a courtesy to our patients, we are happy to submit all insurance claims at no charge. It is up to the patient to fully understand their insurance benefits and to be responsible for that portion of the account that the insurance does not pay.
What prompted you to see dental care at this time?
Reason for leaving former dentist
How long since you have been to a Dentist?
Since had dental X-rays?
Previous Dentist name to call for X-rays?
Previous Dentist Phone #
Have you ever been treated for periodontal (gum) disease?
Do you grind or clench your teeth?
Are you in good health?
Are you presently under the care of a physician?
Are you taking any medications?
(i.e. Coumadin, Bloodthinners, Cortison, Insuline, Digitalis, Dilantin, Fosamax)
Do you have or have you ever had any of the following diseases or problems?
Drug Allergies or Adverse Drug Reactions
Anemia or Blood Disorders
Heart Murmur/Mitrai Valve Prolapse
Respiratory Disease (Asthma)
Convulsions or Epilepsy
High or Low Blood Pressure
NONE OF THE ABOVE
Please click one that applies
Have you had abnormal bleeding associated with previous extractions, surgery or trauma?
Do you have any prosthetic replacements?
(i.e Hip, Knee, Heart Valve)
Have you ever been required to take antibiotics prior to dental procedures?
Upon signing, I understand that I will be charged 1.5% per month (18% annually) on all unpaid balances 90 days past due.