Patient Information Form

Patient Name *

DOB *

Gender *

Marital Status *

Address *

City *

State *

Zip *

Cell Phone

Home Phone

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

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Primary Dental Insurance

Dental Insurance Company

Subscriber Name

Relationship

DOB

Employer Name

Employer Address

Secondary Dental Insurance

Dental Insurance Company

Subscriber Name

Relationship

DOB

Employer Name

Employer Address

Authorization & Release *

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my dependents during the period of such care to third party payers and/or health practitioners.

Financial Policy

PAYMENT IS DUE AT THE TIME OF SERVICE. We accept cash, personal check, Visa, Mastercard, Discover, American Express and CareCredit.

Insurance patients: As a COURTESY TO YOU we will file your insurance claim, provided that we are supplied with complete and correct information. You authorize and request your insurance company (if applicable) to pay benefits directly to the doctor. CO-PAYMENT IS DUE AT THE TIME OF SERVICE. In the event that your insurance company pays less than the actual bill for services, you agree to be responsible for payment of all services rendered on your behalf or your dependents.

Failure to keep your account current will result in Drs. Heringhaus General Dentistry being unable to provide additional services to you or your dependents. In the case of default on your account, you agree to pay collection costs and attorney fees incurred in attempting to collect on your account.

Patient Name *

Date *

Legal Representative/Guardian

Signature

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Patient Signature or Legal Representative/Guardian

Please do not fill in this field.