Responsible Party

Name

Age

Birthdate

Social Security #

Driver License #

Address

City

State

Zip Code

Apt#

Home Phone

Cell Phone

Email

Employer

Business Phone

Ext.

Primary Dental Insurance Information

Policy Holder

Birthdate

Social Security #

Patient Relationship to Insured:

If other:

Insurance Company

Employer

Member ID #

Group #

Phone #

Primary Medical Insurance Information

Policy Holder

Birthdate

Social Security #

Patient Relationship to Insured:

If other:

Insurance Company

Employer

Member ID #

Group #

Phone #

Financial Arrangements
All fees are due at the time services are rendered.


Insurance (name of carrier)

I authorize and request my insurance company to pay directly to the dentist otherwise payable by me. I understand that my dental insurance carrier may pay less then the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. You have my permission to contact me via cell phone to discuss any matters related to my account or that of my dependts.