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WELCOME TO OUR PRACTICE
Legal Name:
Preferred Name:
First
Last
Middle Initial
Address:
Street Address/Box#
City
State
Zip Code
Phone #s:
Home:
Work:
Cell:
Gender:
Female
Male
Marital Status:
Married
Single
Divorced
Widowed
Date of Birth:
Social Security #:
Referral Source:
Paper
Phone Book
Friend Family, who?
Other:
Adult Patients:
Employer:
Phone #:
If applicable, Spouse's Name:
Child(ren) Name(s):
In Case of Emergency, Contact:
Relationship:
Phone #s:
Home:
Work:
Cell:
For Patients under 18 years:
Father:
Date of Birth:
Social Security #:
Address:
Street Address/Box#
City
State
Zip Code
Phone #s:
Home:
Work:
Cell:
Employer:
Phone #:
Mother:
Date of Birth:
Social Security #:
Address:
Street Address/Box#
City
State
Zip Code
Phone #s:
Home:
Work:
Cell:
Employer:
Phone #:
Parent's Marital Status:
Married
Single
Divorced
Whom does child live?
Dental Insurance Information:
Primary:
Subscriber:
Employer:
Policy ID#:
Group #:
Phone #:
Claims Address:
Street Address/Box#
City
State
Zip Code
Relationship to Patient:
Self
Spouse
Parent
Other:
Secondary:
Subscriber:
Employer:
Policy ID#:
Group #:
Phone #:
Claims Address:
Street Address/Box#
City
State
Zip Code
Relationship to Patient:
Self
Spouse
Parent
Other:
Dental Insurance Information:
I hereby authorize Adamsville Family Dentistry to release any and all of my medical (including dental) information to my insurance carrier (or to designated attorney) for purposes of claims administration and evaluation, utilization review and financial audit. This authorization remains valid and effective from the date of signing until revoked in writing. I understand that I may ask for a copy of this authorization. I have read this authorization and understand it. I hereby assign Adamsville Family Dentistry all money to which I am entitled for medical and/or dental expenses relative to the services rendered by them, but not to exceed my indebtedness to said practice. It is understood that any money received from my insurance company, over and above my indebtedness, will be refunded to me when my account is paid in full. I understand that I am financially responsible to the above practice for charges not covered by this assignment. I further agree, in the event of non-payment, to bear the cost of collection, and/or court costs, reasonable legal fees, and also any finance charges and/or interest charged. The financially responsible party for this patient is:
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Signature
Date
Patient Validation:
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