guterdentalcenter.com-Patient Information

PATIENT INFORMATION
Name

First NameLast Name
Date

MonthDayYear
Check if applied

MarriedSingleMinorMaleFemale
SOCIAL SECURITY #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BIRTH DATE

MonthDayYear
Phone Number

Area CodePhone Number
NAME OF EMPLOYER
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IF FULL TIME STUDENT, SCHOOL NAME
GRADE
PERSON RESPONSIBLE FOR ACCOUNT - PLEASE CHECK ONE:

PATIENTGUARDIANSPOUSEFATHERMOTHER
INSURANCE INFORMATION

MINOR CHILO· MAY NEED TO COMPLETE BOTH BLOCKS FOR PARENT INFORMATION INSURANCE INFORMATION ADULTS · COMPLETE PRIMARY INSUFIED DUAl COVERA6E1 ALSO COMPLETE SECONDARY INSURED
PRIMARY INSURED

IF NO INSURANOE COMPLETE fOR RESPONSIBLE PARTY
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone
Email
example@example.com
BIRTH DATE

MonthDayYear
RELATIONSHIP To PATIENT
EMPLOYER
DENTAL INS. CO
SSA#
SUBSCRIBER #
GROUP#
SECONDARY INSURED
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone
Email
example@example.com
Birth Date

MonthDayYear
RELATIONSHIP TO PATlENT
EMPLOYER
DENTAL INS CO
SS#
SUBSCRIBER #
GROUP #
PERSON TO CONTACT IN CASE OF EMERGENCY
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has any member of your family ever been treated in our office?

YesNo
Whom may we thank for referring you to our office?
AUTHORIZATION

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic. photographic and therapeutic procedures as may be necessary for proper dental care. The Information on thiS page and the denial/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals by any method, including electronic transfer.
Patient or Responsible Party

Clear
Date

MonthDayYear
State Driver's License#
METHOD OF PAYMENT
Responsible party currently has an account with this office?

YesNo
Payment in full at each appointment

CashPersonal check
Payment In full at each appointment

VISAMCOther
Card #
Exp. Date

MonthDayYear
I wish to discuss the Dental Office's Financial Policy.
SERVICE CHARGE
If I do not pay the entire new balance with in days of the monthly billing date. a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of % per month (or a minimum charge of $ for a balance under $ ) which IS an annual percentage rate of % applied to the last month's balance. In the case of default of payment. I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees Incurred to effect collection of this account or future outstanding accounts.
Signature

Clear
Should be Empty: