| Patient's Name: |
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DOB: |
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| Preferred Name: |
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SS#: |
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| Name of Spouse: |
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| If patient is under 18/Parent's Name:
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| City:
State:
Zip Code:
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How did you hear about our office?
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| Employer name:
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| If patient is under 18, parent employed by:
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| In case of emergency, who should be notified:
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| What are your dental goals? |
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Do you have Dental insurance that may cover any part of our professional services?
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| If so, Primary Dental Insurance:
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| SS#/ Subscriber ID#:
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| Subscriber Name:
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| Do you have additional Dental Insurance?
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| If so, Secondary Dental Insurance:
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| SS#/ Subscriber ID#:
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| Subscriber Name:
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Are You A Delta Dental Subscriber?:
No, I am not a Delta Dental Subscriber.
Yes, I am Delta Dental Subscriber and I hereby authorize payment of the dental benefits otherwise payable to me directly to Bedford Dental Care. |
REQUIRED FOR ALL PATIENTS
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I hereby authorize the doctor to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with the dental care of the patient above and further authorize and consent that the doctor chooses and employs such assistance as he deems fit. I also understand that previous to treatment, full explanation of the procedure(s) involved will be given by the doctor and/or his staff. I agree to pay for all services rendered by this office. |
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(If the submit button is de-activated,
please complete the Required For All Patients
Section.)
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