Spouse or Responsible Party Information
The following is for:    the patient’s spouse   the person responsible for payment
Name
  Male Female Married Single Child Other
Social Security Number                                           Birth Date:                                
Phone    Work   Ext:    Best time to call
Address
Employment Information
The following is for:    the patient’s spouse   the person responsible for payment
Employer   Occupation  
Address
Employer   Occupation  
Address
Insurance Information
Primary
Name of Insured:   Is insured a patient?    Yes No
Insured’s Birth Date:                            ID# Group#
Insured’s Address:
Insured’s Employer Name  
Address
Patient’s relationship to insured      Self   Spouse   Child   Other
Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

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 accounts.
However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½ % per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied

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 suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone 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.
 
                                                                                                                                                      
Signature of patient, parent or guardian                        Date                           Relationship to Patient:
 
                                                                                                                                                      
Signature of patient, parent or guardian                        Date                           Relationship to Patient:
 
 
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