www.aquadentalaustin.com - Patient Information Form

PATIENT INFORMATION FORM
Patient Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Other Phone Number*
Please enter a valid phone number.
Patient Date of Birth

MonthDayYear
Patient Social Security Number
Marital Status
Patients Employer
E-Mail Address*
example@example.com
Contact preference for Appointment Reminders

EmailPhone
RESPONSIBLE PARTY / INSURANCE INFORMATION
Name of Parent / Subscriber
Subscriber / Policy Holder Address
(If different from above)
Date of Birth

MonthDayYear
Social Security Number
Work Phone Number
Please enter a valid phone number.
Employer
Insurance Name
Group Number
ID Number
Do you have secondary insurance?*

YesNo
SECONDARY INSURANCE INFORMATION
Name of Parent / Subscriber
Subscriber / Policy Holder Address
(If different from PRIMARY)
Date of Birth

MonthDayYear
Social Security Number
Work Phone Number
Please enter a valid phone number.
Employer
Insurance Name
Group Number
ID Number
Referral Information
Whom may we thank for referring you to our practice?
Name
PostcardInsuranceLocationOther
CONSENT FOR SERVICES AND USE AND DISCLOSURE OF HEALTH INFORMATION
RMATION As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Regardless of any dental insurance, a patient may have, the full treatment fees are the responsibility of the patient, not the insurance company or the practice. Full payment of our fees is due at or before the time of treatment. I grant my permission to your assignee to telephone me at home or at my work to discuss matters related to this form. I have read this form, agree to its terms, and certify I’ve provided all information completely and accurately
Signature of patient, parent or guardian*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to Patient
Signature of guarantor of payment/ responsible party

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty:

PATIENT INFORMATION FORM

RESPONSIBLE PARTY / INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

Referral Information

CONSENT FOR SERVICES AND USE AND DISCLOSURE OF HEALTH INFORMATION