PatientInfo adult.pages
Transcription
PatientInfo adult.pages
The benefits of a happy, healthy smile are immeasurable! The information you provide is important for a thorough evaluation, and needs to be updated as changes occur. Adult Patient Information Name Birthdate Sex Age Address Physician Dentist Emergency contact Whom may we thank for referring you? Other family members seen at our office Email for appointment confirmations Preferred Name Contact # City/State/Zip Phone # Phone # Phone # Employment Information Occupation Employer Business Address Work # How long at current job? Social Security # If another person will be helping with this account, please provide his/her information below Name Contact # Relationship to patient Occupation Work # Social Security # Employer How long at current job? Business Address Insurance Information Primary Insurance Company Address Group # Phone # Subscriber Birthdate of Subscriber SS# or ID # Secondary Insurance Company Address Group # Phone # Subscriber Birthdate of Subscriber SS# or ID# I understand that credit bureau reports may be obtained. If necessary, I authorize Shaw Orthodontics to access my records from other caregivers. I acknowledge that I am responsible for all charges incurred regardless of insurance benefits or prearranged parent/ guardian agreements. ! ! Signature! ! ! ! ! ! Relationship to patient!! Date