HEINE FAMILY DENTAL - NEW PATIENT WELCOME

PATIENT INFORMATION

Date: * 🛈 +

ID#/SS#: *

Patient: *

Address: *

City: *

State: *

Zip Code: *

E-mail:

Sex

Male

Female

Age: *

Birthdate: * 🛈 +

Occupation:

Employer:

Employer Address:

Employer Phone:

Spouse's Name:

Spouse's Birthdate: 🛈 +

Spouse's SS#:

Spouse's Occupation:

Spouse's Employer:

Whom may we thank for referring you?

PHONE NUMBERS

Home: *

Cell Phone:

Work:

Ext:

Best time and place to reach you?

IN CASE OF EMERGENCY, CONTACT (Specifiy someone who does not live in your household.)

Name:

Relationship:

Home Phone: *

Work Phone:

Ext:

DENTAL INSURANCE

Who is responsible for this account? *

Relationship to Patient: *

Insurance Company:

Group #:

Is patient covered by additional insurance?

Yes

Subscriber's Name: *

Birthdate: 🛈 +

Relationship to Patient:

Insurance Company:

Group #:

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have insurance coverage with

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am Birthdate SS# financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the Occupation payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature: *

Relationship to Patient: *

Date: * 🛈 +

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