www.floridafacedoc.com - Demographics Form

St. Augustine Oral & Facial Surgical Center
Demographics Form
Patient’s Legal Name*

First NameMiddle NameLast Name
Nickname
Address*
No & street, City, State, Zip
Marital Status
Date of Birth

MonthDayYear
Age
Gender *
Social Security Number
If Student

Full-timePart-timeSchool
Employer
Occupation
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.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Family Members Treated by Dr. Johnson
Is the patient the guarantor?*

YesNo
GUARANTOR

(If different from patient)
Name
Date of Birth

MonthDayYear
Social Security Number
Marital Status
Address
No & street, City, State, Zip
Employer
Relation to Patient
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.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
PHYSICIANS
Full name please

First NameLast Name
Referred by
Orthodontist
General Dentist
Family Physician
PREFERRED PHARMACY
Name
Location
EMERGENCY CONTACT
Name*
Relation to Patient*
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.
Work Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
DENTAL INSURANCE
Please upload your insurance card front and back

Cancelof
Do you have secondary dental/medical insurance?*

YesNo
MEDICAL INSURANCE
Ins. Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured’s Name
Date of Birth

MonthDayYear
Ins. Address
No & street, City, State, Zip
Relation to Patient
Social Security Number
Policy/Certificate Number
Employer’s Name
Group Number
AUTHORIZATION, RELEASE & AGREEMENT TO PAY FOR SERVICES RENDERED
I authorize the doctor and other dentists or health-care professionals (interdisciplinary team members) to perform diagnostic procedures and treatment as may be necessary for proper dental-facial care. I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment and to use the same by the doctor or interdisciplinary team members in scientific presentations or scientific literature. I authorize St. Augustine Oral and Facial Surgery Center to release any information (via mail, fax, phone, or email) including the diagnosis and the records of any treatment or examination rendered to me/my child during the period of such Dental/Medical care to third-party payers, and other entities and/or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents.
CANCELLATION POLICY
Please note that a cancellation fee is charged if you don't show up for your appointment or if you cancel or reschedule your appointment without giving a minimum of 48 hours notice prior to the start of the appointment. To reschedule your appointment, please get in touch with our office on (904) 439-7980
Signature of Patient, Guardian (if minor)*
Name of Patient, Guardian (if minor)*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Demographics Form

GUARANTOR

PHYSICIANS

PREFERRED PHARMACY

EMERGENCY CONTACT

DENTAL INSURANCE

MEDICAL INSURANCE

AUTHORIZATION, RELEASE & AGREEMENT TO PAY FOR SERVICES RENDERED

CANCELLATION POLICY