Adult Intake

Address *

Insurance Company Address

Employer's address

Insurance Company Address

Employer's address

7. I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office any changes in my medical status

I am responsible for payment. Our office is HIPAA compliant and is committed to meeting or exceeding the standards infection control mandated by OSHA, the CDC, and the ADA.
I authorize the dental staff to perform the necessary dental services I may need. *

Clear
This office reserves the right to verify the credit status of potential patients' prior to extending credit for treatment fee and may, at discretion of this office, use the services of one or more credit reporting services. *

Clear
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic. *

Clear
Date

- Month - Day Year
Should be Empty:

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	Yes	No
Abnormal bleeding
Add/ADHD
Any hospital stays
Any operations
Artificial bones / joints valves
Asperger syndrome
Asthma
Autism
Cancer
Congenital heart defect

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