www.richfloresdental.com - Patient Information Form

PATIENT INFORMATION
Patient's Name*

First NameMiddle NameLast Name
Preferred Name
Street Address*
City, State, Zip code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Social Security Number
Marital Status
Gender *
Employer
Email Address*
example@example.com
Who may we thank for referring you to our office?
EMERGENCY CONTACT
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Date of your last dental visit and dental cleaning

MonthDayYear
Date
DENTAL INSURANCE INFORMATION
Subscribers Name
Relationship to Subscriber
Subscribers ID Number
Subscribers Date of Birth

MonthDayYear
Insurance Company
Employer
Group Number

This is our new Financial Agreement that is in effect as of March 1, 2021
Please read, initial and sign at the bottom stating that you agree to our office policy.
All previous information is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
Initial*
I authorize the dentist to release any information, including the diagnosis and records of treatment or examination for myself and my dependent(s), to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.
Initial*
I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behold of my dependents (if any), within 30 days of treatment. Any payments not received within the 30 days will result in a 10% interest charge that will be charged every 30 DAYS until the balance is paid in full.
Initial*
I understand that if I do not provide a 24 HOUR notice for cancelling an appointment, I will be charged a fee of 95.00. Your time is valuable, just as ours is.
Initial*
Signature*

Clear
Responsible Party: (Print)*

First NameLast Name
Date*

MonthDayYear
Date
If a dependent, Responsible party
Relationship to Patient
The signature above, grants Dr. Richard C. Flores, DDS, LLC and staff, permission to treat said child named.
Should be Empty:

PATIENT INFORMATION

EMERGENCY CONTACT

DENTAL INSURANCE INFORMATION

MEDICAL INFORMATION

MEDICAL HISTORY

WOMAN ONLY

Please select your response to indicate if you have or have not had any of the following diseases or problems

This is our new Financial Agreement that is in effect as of March 1, 2021

Please read, initial and sign at the bottom stating that you agree to our office policy.