burnsorthodontics.com - patient information form

Patient Name:

Preferred Name:

Gender:

Birth Date:

Age:

Cell Phone # for text reminders:

Email Address:

Address:

With whom does the patient live?

Whom may we thank for referring you to our office?

For adults, 18 & over, not covered under an insurance policy through a parent/guardian,
please skip to the section ‘Insurance Information’.

FATHER'S INFORMATION

Father’s Name:

E-mail address:

Address if different from child:

Phone #:

Cell # for text reminder:

Marital Status:

Date of Birth:

Occupation:

Employer:

MOTHER'S INFORMATION

Mother’s Name:

E-mail address:

Address if different from child:

Phone #:

Cell # for text reminders:

Marital Status:

Date of Birth:

Occupation:

Employer:

Insurance Information

Before completing this form, call the insurance number on the back of the dental insurance card if you are unsure and ask:

1. Does the patient requiring treatment have Orthodontic Coverage?

2. What is the patient’s Lifetime Orthodontic Maximum?

Does the patient have Dental Insurance with Orthodontic Coverage?

Lifetime Orthodontic Maximum coverage amount: $

PRIMARY DENTAL INSURANCE

Subscriber’s Name:

Date of Birth:

Dental Insurance ID#:

Group #:

Insurance Plan Name:

Insurance Plan Phone#:

Insurance Plan Address:

SECONDARY DENTAL INSURANCE

Subscriber’s Name:

Date of Birth:

Dental Insurance ID#:

Group #:

Insurance Plan Name:

Insurance Plan Phone#:

Insurance Plan Address:

I accept financial responsibility for all services rendered to myself or my child. I authorize the release of any medical information to process my insurance claims or payment assigned to Burns Orthodontics. This office will assist in the prompt filing of all insurance forms; however, I understand that my insurance policy is a contract between me and my insurance company and that I am responsible for any services not covered by my policy. For any reason I were to lose or discontinue my insurance coverage, I am still fully responsible as stated on the contract for the entire amount. It is the guarantor’s responsibility to communicate to their insurance company regarding reimbursement of loss of insurance.

Please sign and date below stating you understand the information above.

Sign:

Date:

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