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Health History Form

Responsible Party Information

the patient's spouse the person responsible for payment
Married Single
(Home) (Work) (Cell) *

(Email) *

Employment Information

the patient's spouse the person responsible for payment

Insurance Information

Yes No
Self Spouse Child Other

Consent for Services

As a condition of your treatment by this office, payment is due at time of service.

I understand and consent to allow any electronic data or information, digital x-ray, digital images to be sent electronically to other healthcare providers, insurance companies, dental laboratories, 3rd party claims house and other entities which may assist in my dental care and/or the processing of my dental insurance claim.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all acounts from the date of the patient examination. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if they are instituted hereunder.

I grant my permission to you or your assignee, to call me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Patient Information

Male Female
(Home) (Work) (Cell) (Email)

Health Information

if new to our office:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Have you ever had any of the following? Please check those that apply:

Yes No
Yes No
Yes No
Coumadin Blood Thinner Birth Control Pills Aspirin

Referral Information

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