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Section Two

Drivers License Number

Nearest relative not living with you

Employer/Business Phone

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

Name

Birth Date/Age/S.S. #

Phone / Drivers license

Address

City/State/Zip

Employer/Business Phone

Spouse or other guarantor information (if different from above)

Name

Relation/S.S.#/Birth Date

Address

City/State/Zip

Phone

Employer / Business

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

City/State/Zip

Primary Insurance Information

Insurance Type:

Dental Medical

Employer

Bus Address

City/State/Zip

Phone Number

Plan Name

Ins. Co. Name

Policy I.D. Number

Ins.Co. Address

City/State/Zip

Phone Number

Group

Insured Party

Relation

Birth Date

Insured Party Sex

Male Female

Address

City/State/Zip

Phone / SSN#

Secondary Insurance Information

Insurance Type:

Dental Medical

Employer

Bus. Address

City/State/Zip

Phone Number

Plan Name

Ins. Co. Name

Policy I.D. Number

Ins.Co. Address

City/State/Zip

Phone Number

Group

Insured Party

Relation

Birth Date

Insured Party Sex

Male Female

Address

City/State/Zip

Phone / SSN#

Dental Information

Reason for today’s visit

Are you in pain?

Yes No

For how long?

Dental Information Part 2

Please indicate any of the following problems by clicking "yes" on the corresponding question

Are you taking any kind of medication, drug, pills?

Yes No

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products):

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Please list any other medication or antibiotic you are allergic to:

Women Only

(Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.)

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills

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.

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.

I authorize the release of information including the diagnosis, x-rays/CT scan, billing, records; examination rendered to me and claims information. This information may be released to:

Spouse

Yes No

Child(ren)(must be 18+)

Yes No

Other (General Dentist, etc.)

Yes No

Information is not to be released to anyone.

Yes No

This Release of Information will remain in effect until terminated by me in writing.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

truForm by PBHS

Main Header

Demographic Information

Patient Information

Section Two

In Case of Emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Insurance Information

Secondary Insurance Information

Dental Information

Dental Information

Dental Information Part 2

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

Medications / Allergies

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products):

Are you now taking:

Are you allergic or had a reaction to:

Please list any other medication or antibiotic you are allergic to:

Please list any other medication or antibiotic you are allergic to:

Women Only

Conclusion

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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Main Header

Demographic Information

Patient Information

Section Two

In Case of Emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Insurance Information

Secondary Insurance Information

Dental Information

Dental Information

Dental Information Part 2

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

Medications / Allergies

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products):

Are you now taking:

Are you allergic or had a reaction to:

Please list any other medication or antibiotic you are allergic to:

Please list any other medication or antibiotic you are allergic to:

Women Only

Conclusion

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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