brynmawrdentist.com - Confidential Information Questionnaire Form

Confidential Information Questionnaire
Patient’s Legal Name *

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Sex*
Social Security Number
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 Address

Street Address Line 2

CityState / Province

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

Street Address

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 Address

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*

YesNo
Contact me via cell phone*

YesNo
Contact me at work*

YesNo
Contact me via e-mail*

YesNo
Leave messages on my home voicemail / Answering Machine*

YesNo
Leave messages on my cell phone voicemail*

YesNo
Leave messages on my work voicemail / Answering Machine*

YesNo
Insurance and Financial Information
Do you have an Insurance Coverage?

YesNo
Insurance Company Name
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber’s Name
Patient’s Relationship to Subscriber

SelfSpouseDependent
Subscriber’s Date of Birth

MonthDayYear
SUBSCRIBER’S SSN / ID #
Group / Program Number
Employer
(if different from above)
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance?*

YesNo
Insurance Company Name
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber’s Name
Patient’s Relationship to Subscriber

SelfSpouseDependent
Subscriber’s Date of Birth

MonthDayYear
SSN(US) / SIN(CAN)
Group / Program Number
Employer
(if different from above)
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Information

You may discuss my healthcare with
Health Care Providers

YesNo
Insurance Companies

YesNo
Other

YesNo
If "Other" please list

CityState / Province

Postal / Zip Code
Confirmations
Do you prefer a confirmation call

No, it is unnecessaryYes, it is a helpful reminder
Assignment & Release
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same
by the doctor in scientific papers or demonstrations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
Signature - Patient / Guardian*
Name - Patient / Guardian*

First NameLast Name
Date*

MonthDayYear
If the above-named Patient is a minor or unable to pay the 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