Copyright @ 2009 Joiner Family Dentistry  |  Contact webmaster (Dr. Jeff) here

123 Albany Ave. SE
Orange City, IA 51041
 dental@joinerdentistry.com
(712) 737-3521  |  (712) 737-4891 fax
CONFIDENTIAL PATIENT INFORMATION

Date

MM		/
DD		/
YYYY
Name

Prefix
First
Last
Suffix
Preferred Name
Sex
Marital status
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Home Phone Number

###		-
###		-
####
Cell Number

###		-
###		-
####
Work Number

###		-
###		-
####
Email
Preferred Contact Method
Birth date

MM		/
DD		/
YYYY
Social Security Number
Employer

RESPONSIBLE PARTY

If same as patient - Skip this section
Name

Prefix
First
Last
Suffix
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Home Phone Number

###		-
###		-
####
Birth date

MM		/
DD		/
YYYY
Social Security Number

PRIMARY DENTAL INSURANCE

Please bring a copy of your insurance card to your appointment.
Insured's Name

First
Last
Insurance Company
Insured's Employer
Insured's Birth date

MM		/
DD		/
YYYY
Insured's Social Security #
ID #
Group #
Local #

SECONDARY DENTAL INSURANCE

A description of the section goes here.
Insured's Name

First
Last
Insurance Company
Insured's Employer
Insured's Birth date

MM		/
DD		/
YYYY
Insured's Social Security #
ID #
Group #
Local #

EMERGENCY CONTACT INFORMATION

Emergency Contact

First
Last
Relationship to patient
Home Phone Number

###		-
###		-
####
Cell Phone Number

###		-
###		-
####

 

Additional Comments

CONSENT

The undersigned hereby attests that the above information is complete and accurate.
I authorize the Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated.
I understand the use of anesthetic agents embodies a certain risk.
I understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the Doctor and that I am fully responsible for all dental fees. These fees are due and payable at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred. I further understand that a rebilling fee will be added to any overdue balance.
I also acknowledge that I have been offered a copy of the offices Notice of Privacy Practices as required by law at the following webpage www.joinerdentistry.com/images/HIPAANotice.pdf.
I also understand that I can refuse parts of this consent by stating so in the comment section above for sections that I disagree with but by so doing the Doctor may refuse treatment.
Electronic Signature*
By typing your full name you (or guardian if under18) are providing your electronic signature
stating the information on this form is complete and accurate to the best of your knowledge.
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