Name
*
First Name
Last Name
Email
*
Sex
*
Phone
*
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
SSN
*
Drivers License Number
*
Previous/Present Dentist
Emergency Contact
*
Phone (Emergency Contact)
*
(###)
###
####
Employer
Length of Employment
Less than 6 months
6 months
1 year
2 years
3 years
4 years
5+ years
Employer Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does your employer provide dental insurance?
*
Are you insured through a spouse/guardian?
*
If you answered 'YES' to either of the above, please:
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Failure to complete the Dental Insurance Information Section and provide your Insurance Card to our office means our office will not be able to submit your claim to your Dental Insurance Company. As a result, the total charges for your treatment will be your responsibility to pay.
Relationship
Name
First Name
Last Name
Phone
(###)
###
####
Employer
*
Length of Employment
*
Less than 6 months
6 months
1 year
2 years
3 years
4 years
5+ years
SSN
Date of Birth
MM
DD
YYYY
Are you insured through a spouse/guardian?
If YES, please provide Insurance Card to our office.
Do you have Dental Insurance coverage?
*
If YES, complete all of the following information.
Name of Insured Party
First Name
Last Name
Date of Birth
MM
DD
YYYY
Relationship
Insured's Employer
Insured's SSN
Insurance Company Name
Insurance Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Member ID
Insurance Group #
Are you under a physician's care now?
*
Have you ever been hospitalized/had a major operation?
*
Have you ever had a serious head/neck injury?
*
Are you taking any medications?
*
Do you take (or have you ever taken) Phen-Fen or Redux?
*
Have you ever taken:
*
Are you on a special diet?
*
Do you use tobacco?
*
If you are female, are you
Are you allergic to:
Do you use controlled substances?
*
Do you have, or have you had, any of the following:
CONSENT
*
I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
PRESCRIPTION MEDICATION POLICY
*
In accordance with Title 21 of the Code of Federal Regulations pain medication will no longer be called in to your pharmacy. Prescriptions for pain medication MUST be picked-up by you in our office. There will be NO EXCEPTIONS to this policy under any circumstance.
FINANCIAL AGREEMENT FOR SERVICES
*
As a condition of your treatment by this office, all financial obligations pertaining to your treatment must be PAID IN FULL at the time treatment is rendered. All emergency treatment must be PAID IN FULL at the time treatment is provided.
Patients who have Dental Insurance:
I understand that the full charges of all dental treatment ultimately is my responsibility to pay in full if my dental insurance carrier denies payment for treatment or renders payment at a lesser amount than estimated by this office. I understand that my portion of treatment costs not covered by my dental insurance MUST BE PAID at the time treatment is provided. I understand that service fees included in any Proposed Treatment Plan provided to me, by this office, will be
guaranteed for six (6) months from the original, printed date on the Proposed Treatment Plan. I understand that if the condition of my dental health changes during this six (6) month period, and before Proposed Treatment is received, that Proposed Treatment may need to be changed and, accordingly, service fees recalculated. I understand that if any balance remains unpaid on my account after three (3) billing cycles, that my account will be turned over to a Collection Agency for full collection of any unpaid balance. I understand that this will affect my Credit Rating.
I grant permission to the office of Suttle Dentistry, PLLC to contact me at home or at my work by mail, telephone, or email to discuss matters related to this Financial Agreement for Services.
