www.drumhellerdentist.com - Confidential Information Questionnaire

Confidential Information Questionnaire
Patient’s Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Sex
Alberta Health Care #.
Prefer to be called
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient’s Address

Street, Apt Number, City, State, Zip/Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Marital Status
Patient’s / Guardian’s Employer
Occupation
Work Address

Street, Apt Number, City, State, Zip/Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse’s Name

First NameMiddle NameLast Name
Spouse’s Employer
Occupation
Spouse’s Work Address

Street, Apt Number, City, State, Zip/Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other family members that are patients here
Who can we thank for referring you to our office?
Emergency Contact Information

Person we may contact in case of an emergency (other than your family home)
Name
Relationship
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Request for Confidential Communication

As my dental care provider, you may do the following with my permission
Contact me at home
Contact me via cell phone
Contact me at work
Contact me via e-mail
Leave messages on my home voicemail
Leave messages on my cell phone voicemail
Leave messages on my work voicemail
Insurance and Financial Information
Do you have an Insurance Coverage?
Insurance Company Name
Insurance Address

Street, Apt Number, City, State, Zip / Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Plan or Group
Subscriber’s Name
Patient’s Relationship to Subscriber
Subscriber’s Date of Birth

MonthDayYear
Alberta Health Care #.
Group / Program Number
Employer
(if different from above)
Employer's Address

Street, Apt Number, City, State, Zip / Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance?
Insurance Company Name
Insurance Address

Street, Apt Number, City, State, Zip / Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Plan or Group
Subscriber’s Name
Patient’s Relationship to Subscriber
Subscriber’s Date of Birth

MonthDayYear
Alberta Health Care #.
Group / Program Number
Employer
(if different from above)
Employer's Address

Street, Apt Number, City, State, Zip / Postal Code

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Information

You may discuss my healthcare with
Health Care Providers
Insurance Companies
Other
If "Other" please list

CityState / Province

Postal / Zip Code
Confirmations
Do you prefer a confirmation call
Assignment & Release
I hereby authorize (1) any available insurance benefits to be paid directly to my dentist, (2) the release of my dental health care information for any of my dental health care insurance claims, (3) the use of my dental records by my dentist in any professional manner that he/she determines, (4) the making of videotapes, photographs, and x-rays of my dental care treatment (collectively “My Images”), and (5) my dentist’s use of My Images in scientific papers, demonstrations and/or presentations without compensation to me. I agree that to the extent the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured cost (the “Uninsured Costs”) in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.
Signature - Patient / Guardian
Name - Patient / Guardian

First NameLast Name
Date

MonthDayYear
If the above-named patient is a minor or unable to pay his/her Uninsured Costs, the undersigned agrees to guaranty the payment of such Uninsured Costs to the Patient’s dentist in accordance with his/her payment terms and policies
Signature - Guarantor of Patient
Date

MonthDayYear
Should be Empty:

Confidential Information Questionnaire

Emergency Contact Information

Request for Confidential Communication

Insurance and Financial Information

Release Information

Confirmations

Assignment & Release