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9710 PARK PLAZA AVENUE
SUITE 109
LOUISVILLE KENTUCKY 40241

PAUL ABBOTT DMD
SAMANTHA JO JOHNSON DMD MSD

PHONE: 502-412-3309
INFO@ADVANCED-ENDO.COM
FAX: 502-412-3340

Section Two

Drivers License Number

Nearest relative not living with you

Phone

Employer / Business

Personal Payment Type

Cash Check Credit Card

In case of emergency

Please contact:

Phone / Relation

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account (if self, skip to next section)

Name / Social Security Number

Birth Date / Age

Responsible party phone

Address

Driver's License Number

Employer / Business

Spouse or other guarantor information (if different from above)

Name / Relation

Social Security Number / Birth Date

Address

Home Phone / Employer / Work Phone

Are you a student?

Full-time Part-time Not a student

School Information

School Name

Address

Primary Insurance Company

Insurance Type:

Dental Medical

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Address

City / State / Zip

Phone Number

Group # / Group Name

Insured Party

Relation

Sex

M F

Birth Date

Insured Party Address

City / State / Zip

Phone / Social Security #

I.D. #

Secondary Insurance Company

Insurance Type:

Dental Medical

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Address

City / State / Zip

Phone Number

Group # / Group Name

Insured Party

Relation

Sex

M F

Birth Date

Insured Party Address

City / State / Zip

Phone / Social Security #

I.D. #

Women: Are you

Pregnant / Trying to get pregnant?

Yes No

Nursing?

Yes No

Taking oral contraceptive?

Yes No

Have you ever had any serious illness not listed?

Yes No

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

✔

I permit the office to communicate with me via text message on my cell phone.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

FEES & PAYMENTS
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature of patient: (Parent or Guardian if Minor)

Click to Sign

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

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

truForm by PBHS

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Demographic Information

Patient Information

Section Two

In case of emergency

Who will be responsible for your account (if self, skip to next section)

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Insurance Company

Secondary Insurance Company

Medical History

Medical History

Women: Are you

Medication and Allergies

Are you allergic to any of the following

Please check any of the following conditions that apply to you

Have you ever had any serious illness not listed?

Conclusion

Verification

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Main Header

Demographic Information

Patient Information

Section Two

In case of emergency

Who will be responsible for your account (if self, skip to next section)

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Insurance Company

Secondary Insurance Company

Medical History

Medical History

Women: Are you

Medication and Allergies

Are you allergic to any of the following

Please check any of the following conditions that apply to you

Have you ever had any serious illness not listed?

Conclusion

Verification

Click to Sign

Click to Sign

Click to Sign

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.

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