www.centreplacedental.com - Patient/ Guarantor Information

Thank you for selecting Centre Place Dental, P.C

We will strive to provide you with the best possible care. To help us meet your healthcare needs, please fill out this form completely. If you have questions or need assistance, please ask and we will be happy to help.
Patient/ Guarantor Information
Check appropriate box

MinorSingleMarriedDivorcedWidowedSeparated
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Soc Sec#
Email address*
example@example.com
Patient/ Guarantor Employer
Work Phone Number
Please enter a valid phone number.
Spouse, Parent, Other - Relationship to patient
Name
Date of Birth

MonthDayYear
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Soc Sec#
Email address
example@example.com
Employer
Work Phone Number
Please enter a valid phone number.
If the patient is a student, name of School/ College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person to contact in Case of Emergency
Phone Number
Please enter a valid phone number.
Address
Who is responsible for the patient’s medical care?
Dental Insurance Information
Name of Insured
Relationship to the Patient
Date of Birth

MonthDayYear
Soc Sec #
Employer
Insurance Company
Group #
Group Name
Policy ID#
DO YOU HAVE ANY ADDITIONAL INSURANCE?

Please let the front desk know
Authorization and Release
I certify that the information provided above is true and correct to the best of my knowledge and belief. I authorize the physician to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my dependent during the period of such care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the doctor’s office, and insurance benefits are otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I understand I am responsible for all copays, deductibles, co-insurance, and balances. I understand and agree that I am ultimately responsible for any unpaid balances. I understand and agree that any cellular or landline phone numbers and email addresses provided by myself to this office and to any of our service providers, now and in the future, may be used as a means to contact me, and that this office and our service providers may leave messages for me manually and by using automatic systems such as by artificial or prerecorded voice.

I also agree that this office and any service providers may contact me by sending text messages and emails to any phone number or email address I provide to this office or service providers. I consent to receive such text messages and emails which may identify the name of this office or service provider sending the communication, and which may disclose the nature of the communications.
Signature of Patient/ Guarantor*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Thank you for selecting Centre Place Dental, P.C

Patient/ Guarantor Information

Dental Insurance Information

DO YOU HAVE ANY ADDITIONAL INSURANCE?

Authorization and Release

Acknowledgement of Receipt of HIPPA Policies and Procedures