Personal lnforrnation Date (moryo-

O Trimble Dental lnc.
Personal lnformation
Rev 01/04/08
WglCOme tO OUf familloun,.,
practiceandthankyourorselectingusroryourdental
treatment. To gather the information that is needed to establish you as a patient we would ask you to fili out the form
below completely. lf you have any questions or need assistance, please ask, and we will be happy to help'
Personal lnformation
Name
(lr/iddle
(First)
(Last)
Birth
lnitial)
Date-
Age
-
SS#
Phone (cell/Page
Phone (H)
Date
(nickname)
Family lviembers Name(s) and Relationship(s)
--
State
Driver License No.
State
City
Home Address
_
Zip
How Long at present Address
lfyouareastudent,pleaselistparentsname(s)andaddress(es)
Employment lnformation
[/lay we call you at
Your Occupation
City
Address
State
How Long have you been employed there
tulltime
Spouses Name
SS#
Soouses
ext
Work Phone
Your Employer
part time
Work?
yes
ZiP
- Date_
Birth
phone
Emolover
-
Emergency Contact lnformation
Nearest relative not living with
you
Phone
Phone
ln case of an emergency please contact
How Did You Find Us
Referred by
Yellow pages
Reference information from your lnsurance provider
Referred by a health care professional
B
o
tr
B
Other
(over)
KP:R6
Personal
lnforrnation
Date
(moryo-
no
Trimble Dental lnc.
Financial Agreement
Rev 01/04//08
OUR OFFICE POLICY is that payment is kindly required for att expenses at each visit.
Below are the options that we have available for payment, please initial your selection
_
Check or Cash 5% Discount
_Credit
Card
Expiration
(prease circle):
Date:_
- for payment in fuil at day of service
MESter Card or Visa
Name on Card:
Signature
Account Number:
Dental lnsurance
1.
2.
Expenses not covered by your insurance company are required to be paid in full by you on the day of
your visit.
o This would include any deductible amount, co-payment, non-covered services and products, etc.
Your contract is between your insurance company and you. We have no part in that.
. lnsurance is a benefit that you or your employer has purchased for you and typically does not cover all
.
charges and may have annual coverage limits.
Our concern is in you, not the insurance company. Treatment that we provide is determined by your
dental needs and conditions, NOT by your insurance coverage.
Authorizations
1. I hereby authorize Trimble Dental to release any information requested by my insurance company(ies)
acquired in the course for treatment.
2. I understand that I am personally financially responsible for ALL charges regardless of my insurance
3.
4.
5.
6.
7.
8.
9.
situation and ask Trimble Dentalto bill my insurance company.for me.
I understand that I am expected to pay, at the time of each visit, the portion of my charges that my insurance
company would pr:obably not cover, and that I will be required to pay the insurance portion of my charges
after 45 days if it is unpaid by my insurance company.
I understand that my account will be considered PAST DUE after 45 days and a finance charge of
1.S%/month will be added to my account.
I understand that I am responsible for any charges incurred with collection/legal{ees by this office if I default
on my account.
I understand that a $25 charge will be incurred for all returned checks.
I understand that if I am using my credit card for payment, I authorize Trimble Dental to bill my credit card
directly.
I hereby authorize and direct my insurance benefits to be paid directly to this office.
I understand if I fatl2 appointments or cancel 3 appointments within 48 hrs of the appointment, I may no
longer be considered a patient of the practice and that this is at the discretion of Trimble Dental.
I have read and understand the above
Print Patient Name
Print Legal Guardian Name
Patient Signature
Legal Guardian Signature
Date
Date