PATIENT INFORMATION

REGINA F. R. DE LEON, DMD, MMSc, INC

Practice Limited to Endodontics

450 Sutter Street, Suite 1426 San Francisco, CA 94108

(415) 434-3080
PATIENT INFORMATION
Today's Date

Month Day Year
Date
Name
Gender

Male Female
Home Address (Apartment/Unit No., Street)
Home Address (City, State, Zip code)
Home #
Cell Phone #
Email
example@example.com
Birthdate

Month Day Year
Date
Age
Person Responsible for the Account
Employment
Occupation
Employer's Name
Work Address
Work Phone
Email
example@example.com
Spouse/Domestic Partner/Significant Other/Parent
Name
Gender

Male Female
Occupation
Employer's Name
Work Address
Phone Number
...if patient is a minor
School Enrolled in
Insurance Information

(If you have dental insurance, please complete the following and apprise us of any changes that may occur in your coverage.)
Primary Coverage
Subscriber Name
Employer
Insurance Company
Insurance Company Address
Group or policy #
Subscriber Soc. Sec #
Subscriber Birth date

Month Day Year
Date
Secondary Coverage
Subscriber Name
Employer
Insurance Company
Insurance Company Address
Group or policy #
Subscriber Soc. Sec #
Subscriber Birth date

Month Day Year
Date
Assignment & Release
I recognize that I am financially responsible for any services rendered to me at this office. Treatment fees will be presented prior to treatment. Payment in full is appreciated at the time of service. We accept cash, credit cards and checks. Returned checks will have a $35.00 bank charge applied to the patient’s account. As a special service to me, insurance claims may be prepared and submitted on my behalf. I hereby authorize this office to release any information to my insurance company that is needed for the filing of my claims. Changes or additions to your insurance must be provided at each appointment for proper insurance submission. We will be unable to resubmit insurance claims due to inaccurate information provided or on file.
Appointments
We request 48 hours notice for changes in your scheduled appointment. If insufficient notice is given, or an appointment is missed, a disappointment fee equal to the scheduled procedure for that date may be applied to your account (minimum $85.00 If three (3) appointments are cancelled or missed, the patient will be dismissed from our office.
Confidentiality
I have been informed of this office’s Privacy Policies and have been instructed as to the location of the office wide policy on display so that I may review the policy at my discretion, I am also aware that a copy of these policies are available to me in print if requested. I permit communication between my doctors, dentist and family members/guardians as is deemed necessary for successful treatment outcomes.
Dental History
Referred by
Current Dentist
How Long?
Signature (Parent Signature if patient is under 18 years of age)

Clear
Date

Month Day Year
Date
Should be Empty:

PATIENT INFORMATION

Employment

Spouse/Domestic Partner/Significant Other/Parent

...if patient is a minor

Insurance Information

Primary Coverage

Secondary Coverage

Assignment & Release

Appointments

Confidentiality

Dental History