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If the following applies, please fill out completely. We will need a copy of your Dental Insurance card.
Welcome to Our Office!
PRIMARY DENTAL INSURANCE:
Name of Insured Person (Employee):_____________________________________________Relationship to Patient:__________________ Member ID#:________-______-_________ Date of Birth:_________________________________________________________________ Patient Information:
Please circle: Ms. Mr. Mrs. Dr. Other ___________
Getting to the ROOT of the Problem Employer/Retired From:_________________________________________________ Length of Employment:________________________ _________________________________ ____________________________________ ________ _________________________ Name of Insurance Company:__________________________________________Group#____________ Phone:______________________ Address:_________________________________________________City:_____________________State:______ Zip:_________________ Address:___________________________________________ Apt#______ City:____________________State:____Zip:_________ SECONDARY DENTAL INSURANCE:
Home #:______________Work #:______________ Cell #:______________ Email:_______________________________________Social Security Number:______-_______-_______ Date of Birth:___________ Sex: M F Spouse’s Name:_______________ Name of Insured Person (Employee):_____________________________________________Relationship to Patient:__________________ Your Employer:_________________________________Employer’s Address:____________________________________________ Member ID#:______-______-_______ Date of Birth:_______________ Employer/Retired From:_________________________________ General Dentist:_____________________ Physician:_______________________ Referred By: _______________________________ Name of Insurance Company:_________________________________________Group#____________ Phone:_______________________ Is the patient a full-time student? No Yes Name of School__________________________________________________ Address:________________________________________________City:_____________________State:______ Zip:__________________ In case of emergency contact: Name:_______________________Work Number:______________Home Number:_______________ I hereby authorize the provider to file my insurance and benefits to be paid directly to the provider. MEDICAL HISTORY: Please check Y for “yes” or N for “no” for any of the following which may apply to you now or in the past:
I also understand that when my particular insurance is filed: I authorize the release of any information related to my claim to my insurance company.
I am ultimately responsible for the balance on my account for any professional services rendered regardless of the amount my insurance pays toward my account. We ask that patients with insurance pay estimated portion of the cost of treatment; at the time service is received.
Have you ever taken Bisphosphonates? _______ (i.e. Fosamax, Aredia, Zometa, Actonel, Boniva, Skelid, Didronel, Bonefos Ostec) Any balance not paid by my insurance will be due within two weeks of the statement Any other diseases or problems? ______________________________________________________________________________ date, a LATE FEE and/or a SIMPLE INTEREST CHARGE may be added to the account.
Have you ever had an unusual reaction to latex, anesthetics, or drugs such as Penicillin, Erythromycin, Novacaine, Codeine, The INTEREST CHARGE will be a periodic rate of 1.5 % per month, which is an ANNUAL
Aspirin, Sulfa, or any other medications? PERCENTAGE RATE of 18% applied to the last month’s balance. In the case of default of
If yes, Please explain: ____________________________________________________________________________ payment, I promise to pay any legal interest on the balance due, together with any collection What Medications are you taking at present?_____________________________________________________________________ costs and reasonable attorney fees incurred to effect collection on this account.
Have you taken Aspirin or Ibuprofen in the last 72 hours? Yes No; If yes: AspirinIbuprofen;Howmany?______________ If patient is under the age of 18 years old, please complete the following:
No; If yes,what month? ______________________________________________________ Responsible Party:____________________________________ Date of Birth: ___________ Social Security:__________________ THE PURPOSE of endodontic treatment or root canal treatment is to save the tooth rather than remove it. Although treatment
has a high degree of success, it can not be guaranteed. Occasionally, a tooth that has had a root canal treatment may require Address:________________________________________City:________________________State:______________Zip:_________ re-treatment, surgery or even extraction.
Treatment is usually a non-surgical procedure, but in some cases, a surgical approach is necessary. Before any treatment is begun the reason(s) will be explained, including alternative modes of therapy. Occasionally, pre-medication may be indicated.
Home #:_____________________Work #:_____________________ Relationship to Patient:_______________________________ This will be discussed in advance.
PLEASE NOTE: The fee will not include a permanent filling or crown on the tooth. You must return to your
I HAVE/DO NOT HAVE (please circle one) dental insurance. I am financially responsible for fees incurred at the
general dentist to have that treatment completed.
time of service.
I consent to necessary treatment and authorize the release of any information needed for continued treatment.
_______________________________________________________________ _________________________________ _______________________________________________________________ _________________________________ SIGNATURE OF PATIENT (CUSTODIAL PARENT/GUARDIAN OF MINOR) SIGNATURE OF PATIENT (CUSTODIAL PARENT/GUARDIAN OF MINOR) For Office Use Only: Copy of insurance card provided: Yes____________ No____________ Initials____________
PLEASE: How are you feeling today:
Please continue to
the reverse side and complete.
If the following applies, please fill out completely. We will need a copy of your Dental Insurance card.
Welcome to Our Office!
PRIMARY DENTAL INSURANCE:
Name of Insured Person (Employee):_____________________________________________Relationship to Patient:__________________ Member ID#:________-______-_________ Date of Birth:_________________________________________________________________ Patient Information:
Please circle: Ms. Mr. Mrs. Dr. Other ___________
Employer/Retired From:_________________________________________________ Length of Employment:________________________ _________________________________ ____________________________________ ________ _________________________ Name of Insurance Company:__________________________________________Group#____________ Phone:______________________ Address:_________________________________________________City:_____________________State:______ Zip:_________________ Address:___________________________________________ Apt#______ City:____________________State:____Zip:_________ SECONDARY DENTAL INSURANCE:
Home #:______________Work #:______________ Cell #:______________ Email:_______________________________________Social Security Number:______-_______-_______ Date of Birth:___________ Sex: M F Spouse’s Name:_______________ Name of Insured Person (Employee):_____________________________________________Relationship to Patient:__________________ Your Employer:_________________________________Employer’s Address:____________________________________________ Member ID#:______-______-_______ Date of Birth:_______________ Employer/Retired From:_________________________________ General Dentist:_____________________ Physician:_______________________ Referred By: _______________________________ Name of Insurance Company:_________________________________________Group#____________ Phone:_______________________ Is the patient a full-time student? No Yes Name of School__________________________________________________ Address:________________________________________________City:_____________________State:______ Zip:__________________ In case of emergency contact: Name:_______________________Work Number:______________Home Number:_______________ I hereby authorize the provider to file my insurance and benefits to be paid directly to the provider. MEDICAL HISTORY: Please check Y for “yes” or N for “no” for any of the following which may apply to you now or in the past:
I also understand that when my particular insurance is filed: I authorize the release of any information related to my claim to my insurance company.
I am ultimately responsible for the balance on my account for any professional services rendered regardless of the amount my insurance pays toward my account. We ask that patients with insurance pay estimated portion of the cost of treatment; at the time service is received.
Have you ever taken Bisphosphonates? _______ (i.e. Fosamax, Aredia, Zometa, Actonel, Boniva, Skelid, Didronel, Bonefos Ostec) Any balance not paid by my insurance will be due within two weeks of the statement Any other diseases or problems? ______________________________________________________________________________ date, a LATE FEE and/or a SIMPLE INTEREST CHARGE may be added to the account.
Have you ever had an unusual reaction to latex, anesthetics, or drugs such as Penicillin, Erythromycin, Novacaine, Codeine, The INTEREST CHARGE will be a periodic rate of 1.5 % per month, which is an ANNUAL
Aspirin, Sulfa, or any other medications? PERCENTAGE RATE of 18% applied to the last month’s balance. In the case of default of
If yes, Please explain: ____________________________________________________________________________ payment, I promise to pay any legal interest on the balance due, together with any collection What Medications are you taking at present?_____________________________________________________________________ costs and reasonable attorney fees incurred to effect collection on this account.
Have you taken Aspirin or Ibuprofen in the last 72 hours? Yes No; If yes: AspirinIbuprofen;Howmany?______________ If patient is under the age of 18 years old, please complete the following:
No; If yes,what month? ______________________________________________________ Responsible Party:____________________________________ Date of Birth: ___________ Social Security:__________________ THE PURPOSE of endodontic treatment or root canal treatment is to save the tooth rather than remove it. Although treatment
has a high degree of success, it can not be guaranteed. Occasionally, a tooth that has had a root canal treatment may require Address:________________________________________City:________________________State:______________Zip:_________ re-treatment, surgery or even extraction.
Treatment is usually a non-surgical procedure, but in some cases, a surgical approach is necessary. Before any treatment is begun the reason(s) will be explained, including alternative modes of therapy. Occasionally, pre-medication may be indicated.
Home #:_____________________Work #:_____________________ Relationship to Patient:_______________________________ This will be discussed in advance.
PLEASE NOTE: The fee will not include a permanent filling or crown on the tooth. You must return to your
I HAVE/DO NOT HAVE (please circle one) dental insurance. I am financially responsible for fees incurred at the
general dentist to have that treatment completed.
time of service.
I consent to necessary treatment and authorize the release of any information needed for continued treatment.
_______________________________________________________________ _________________________________ _______________________________________________________________ _________________________________ SIGNATURE OF PATIENT (CUSTODIAL PARENT/GUARDIAN OF MINOR) SIGNATURE OF PATIENT (CUSTODIAL PARENT/GUARDIAN OF MINOR) For Office Use Only: Copy of insurance card provided: Yes____________ No____________ Initials____________
PLEASE: How are you feeling today:
Please continue to
the reverse side and complete.

Source: http://www.gcendo.com/appointments/15506%20GCE%20Patient%20Info.pdf