Patient Information

7930 Frost Street, Suite 101 San Diego, CA 92123 Phone 858-492-9977 Fax 858-492-9910 Orthodontics 858-810-7387 www.poisetandassociates.com.
Childs Name
Todays Date

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Date
Whom may we thank for referring you?
Medical Doctor
Medical Doctor
Family/Friend
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Parent's Information
Title

Dr.Mr.Mrs.Ms.
Name
Relationship to Child
Address

Address

Street Address Line 2

CityState

Zip
Email
example@example.com
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Drivers License
State
Occupation
Employer Name
Employer Address

Address

Street Address Line 2

CityState

Zip
Parents Dentist
Parent's Marital Status

MarriedDivorcedSeparatedWidowedSingle
Parent's Information
Title

Dr.Mr.Mrs.Ms.
Name
Relationship to Child
Address

Street Address

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email
example@example.com
Drivers License
State
Occupation
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Marital Status

MarriedDivorcedSeparatedWidowedSingle
Insurance Information
Primary Insurance
Name of Insured
Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Social Security Number
Insurance ID#
GroupPlan
Name of Employer
Name of insurance Company
Phone Number

Area CodePhone Number
Secondary Insurance
Name of Insured
Name of Insured
Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Social Security Number
Insurance ID#
Group Plan
Name of Employer
Name of insurance Company
Phone Number - Insurance Company

Area CodePhone Number
Financial Responsibility and Assigment of Benefits
I understand that a finance charge of 0.83% per month will be added to all balances over 90 days. If legal action and/or assignment to an attorney or collection agency should become necessary to collect my account, I agree to pay all cost of collection including court costs, collection agency commissions and cost, and reasonable attorney fees.

Authorization to Release Health Information | authorize the doctors and staff of Poiset and Associates to obtain, use and disclose my child's Protected Health Information to carry out treatment, payment activities and healthcare operations. This information will include but is not limited to my child's health history, diagnostic records, diagnosis and treatment provided.
ParentGuardian Signature

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Date
Notices of Privacy Practices
I have reviewed the document entitled "Notice of Privacy Practices" for Poiset and Associates. I understand and agree with the content of this document, especially paragraph 1A.
ParentGuardian Signature

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Date

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Date
Authorization to Release Health Information
I authorize the doctors and staff at Poiset and Associates to obtain, use and disclose my child's Protected Health Inforation to carrry out treatment, payment activities and healthcare operations. This information will include, but is not limited to, my child's health history, diagnostic records, diagnosis and treatment provided.
ParentGuardian Signature

Clear
Date

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Date
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