www.aureliadds.com - Patient Information Form

Patient Information Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Print blank form to fill by hand (Click Here)
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age
Gender*
Home Address*
Street Address, City, State, Zip
Marital Status
If "Other" Please Explain
Cell Phone Number*
Please enter a valid phone number.
Home or Secondary Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Health Information
Date of last dental visit

MonthDayYear
Reason for this visit
Have you ever had any of the following? Please check all that apply
AIDS/HIVAnemiaArthritisAsthmaBlood DiseaseChemotherapyDiabetesDizzinessEpilepsyFaintingGlaucomaHay FeverHead InjuryHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisorderNervous DisorderPacemakerCurrent PregnancyRadiation TxRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal Disease
Allergies: Drug
Drug List
Allergies: Other
Other List
Artificial Joints
Date

MonthDayYear
Date
Cancer
Type?
Heart Attack
Date

MonthDayYear
Date
Thyroid
HypoHyper
Other
If "Other" List
Please list current medications
Please explain any health issues that need further clarification
Please explain any complications the patient has had following dental treatment
Has the patient been admitted to the hospital or needed emergency care during the past two years?*

YesNo
If so, please explain*
Is the patient now under the care of a physician?*

YesNo
If yes, please explain*
Name of physician
Phone Number
Please enter a valid phone number.
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Responsible Party Information*

Same as PatientOther
Responsible Party Information

The following information is for the person responsible for the payment of services
Person Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Gender
Marital Status
If "Other" Please Explain
Address
Street Address, City, State, Zip
Cell Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Dental Insurance Information

Please note that this insurance may be different than your medical insurance carrier
Primary Insurance
Name of Subscriber

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Employer Name
Insurance Carrier Name
Insurance Carrier Provider Phone Number
Please enter a valid phone number.
Policy ID# (or SSN)
Group#
Claims Mailing Address
Street Address, City, State, Zip
Patient’s relationship to Insured Subscriber
If "Other" Please Explain
Do you have Secondary Insurance?*

YesNo
Name of Subscriber

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Employer Name
Insurance Carrier Name
Insurance Carrier Provider Phone Number
Please enter a valid phone number.
Policy ID# (or SSN)
Group#
Claims Mailing Address
Street Address, City, State, Zip
Patient’s relationship to Insured Subscriber
If "Other" Please Describe
Referral Information
Whom may we thank for referring you to our practice?
If "Other" Please Describe
Name of person or office referring you to our practice
Consent for Services
As a condition of treatment by this office, patients are expected to pay their balance at the time of service or to make financial arrangements in advance. The practice depends upon the reimbursement from patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment.

As a courtesy, for those patients who carry dental insurance, the practice will send claims to the patient's insurance company first. We will then send a statement for any remaining balance to the responsible party. This office cannot render services on the assumption that our charge will be paid by an insurance company. We ask that all patients update us immediately with any changes to insurance coverage.

A late fee or service charge of 1.5% per month (18% annum) on the unpaid balance or $10.00 minimum per month may be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition, and I further agree to pay all costs and reasonable attorney fees if suit shall be instituted hereunder.
I have read the above conditions of treatment and payment and agree to their content.
I grant my permission to you or your assignee to telephone me at home, or by mobile phone, or at my work to discuss matters related to this form.
I grant my permission to you or your assignee to communicate with me electronically at the email address provided. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am responsible for providing the dental practice any updates to my email address. I can withdraw my consent to electronic communications at any time by calling 248-651-6810.
I have read this practice's Financial Policy and agree to its terms and conditions.
Read the Financial Policy Form (Click here)
I have read this practice's Notice of Privacy Practices and agree to its terms and conditions.
Read the Notice of Privacy Practices Form (Click here)

Patient Information Form

Health Information

Have you ever had any of the following? Please check all that apply

Responsible Party Information

Dental Insurance Information

Primary Insurance

Referral Information

Consent for Services

Radiograph and Records Request