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Responsible Party (if different than above)

Person responsible for the account:

Patient Guardian Father Mother

Name

Telephone # during the day

Address

City / State / Zip

Dental Insurance Information

Name of insured

Relationship to patient / Birth date / SS #

Name of employer / ID #

Address of employer

City / State / Zip

Insurance company / Group #

Insurance company address

City

Method of Payment

Cash and personal checks are accepted as your treatments are provided.

Yes No

Dental insurance is your responsibility, but we can help. Regardless of what we might calculate as your dental benefit in dollars, we must stress that you are responsible for the total treatment fee. As a courtesy, we accept
assignment of benefit payments from most insurance companies. This will reduce your immediate, out-of-pocket expenditures. Estimates are based on limited information obtained from your insurance co.

Yes No

MasterCard, Visa, Discover and American Express

Yes No

Healthcare financing program, which when you are accepted, will allow extended small monthly payments for treatment received.

Yes No

I hereby authorize the doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with the dental care of the patient above and further authorize and consent that the doctor chooses and
employs such assistance as he deems fit. I agree to pay for all services rendered by this office.

Signature of Responsible Party

Click to Sign

Date:-------------

Relationship

Medical History

Name of physician / Phone #

Do you now have or have you ever had any of the following? Please select Yes in the appropriate boxes.
*If yes to any of the starred conditions, please call prior to your appointment… pre-medication may be required.

For Women Only

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medications change, I shall inform the dentist and staff at the next appointment without fail.

Patient Signature (Parent or Guardian)

Click to Sign

Date:-------------

truForm by PBHS

Main Header

Patient Information

Patient Information

Responsible Party (if different than above)

Insurance Information

Dental Insurance Information

Method of Payment

Method of Payment

Click to Sign

Dental History

Please indicate any of the following problems by selecting Yes in the corresponding box

Medical History

Medical History

Medication & Allergies

Are you taking any of the following

Are you allergic to or had a reaction to

For Women Only

Conclusion

Click to Sign

PBHS truForm is best utilized in portrait mode.

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Main Header

Patient Information

Patient Information

Responsible Party (if different than above)

Insurance Information

Dental Insurance Information

Method of Payment

Method of Payment

Click to Sign

Dental History

Please indicate any of the following problems by selecting Yes in the corresponding box

Medical History

Medical History

Medication & Allergies

Are you taking any of the following

Are you allergic to or had a reaction to

For Women Only

Conclusion

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.