Patient Intake Form

Insurance

*We must emphasize that as your dental care provider, our relationship is with you our patient, not with your insurance company. As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits will determine the amount paid. We will,of course, do all we can to make sure your estimate is as accurate as possible.
Do you have dental insurance?*

YesNo
Subscriber Name
Subscriber Birth Date

MonthDayYear
Relationship to Patient
Subscriber SSN/ID
Group Number
Subscriber Employer
Insurance Company
Insurance Company's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company's Phone Number

Area CodePhone Number

Assignment and Release
I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Signature

Clear

Financial Policy
Payment or Copayment is due at time of services

* We accept all major debit and credit cards, along with cash and checks.

* We offer financing through Clearwater Credit Union.

There is a finance charge of 18% on all accounts over 90 days due.

If this account is not paid when due, and Jensen Dental should retain an attorney or collection agency for collection, I agree to pay all costs of collection including reasonable interest, reasonable attorney's fees (whether or not a lawsuit is filed) and reasonable collection agency fees in the amount of 50% of the balance due.
No Show/Cancelation Policy
A cancellation is considered late when the appointment is canceled less than one working day before the appointed time. A no show is when a patient misses an appointment without canceling. In either case we will charge the patient a missed appointment fee. Fee will be based off of type and length of appointment.
Signature*

Clear
Should be Empty:

	Yes	No
Do you require antibiotics before dental treatment?
Are you currently in pain?
Do you now or have you had any pain/discomfort in your jaw joint?
Is there anything you would like to change about your smile?
Have you ever had gum disease?
Have you ever had a deep cleaning or scaling and root planing?
Do you have Dental Anxiety?

New Patient Enrollment