First Name: Last Name: Prefer to be called:
Date Of Birth: Age: Gender:
Address: City: Postal Code:
Cell Phone: Home Phone: Work Phone:
Best Way To Contact: Best Time To Contact:
May we contact you by Text/Email Intials: Email:
How did you hear about us: Are other family members pt. at our office: Name:
Emergency contact: Phone: ID for prescription:
Family Physician: Phone: Address:
Financial Agreement / Authorization
Person Responsible for Account
Name: Relationship: Phone No.:
Minors must be accompanied by a parent or legal guardian. If the parents are not together, the person accompanying will be responsible for the treatment and payment of the service. We accept the following forms of payment: Cash/ Card/ Insurance Assignment. We do not accept personal cheques. Please provide following information for assignment purposes.
Primary Insurance Plan
Secondary Insurance Plan
As a professional courtesy to our most valued patients, we will accept insurance assignment under the following terms and conditions:1. Any amounts not paid for under your insurance plan and due to our office will be paid by you. Payment is due at the time of service, including any deductibles or co-payments. 2. When your treatment requires laboratory services, a deposit equal to the estimated laboratory fee is required at the time that your dental impressions are taken. 3.While we will do our best to obtain accurate information regarding your eligibility and benefits, in some cases the insurance companies will not provide us with the most up to date information resulting in inaccuracies. No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference. 4. If full payment has not been made within 30 days of the claim submission any outstanding balance will be your responsibility should your insurance company deny all, or a portion of your claim. The balance will be charged to your credit card on file and a receipt of any charges will be mailed to you. I have read or have had read to me the privacy and office policies and insurance assignment conditions. I understand that I am responsible to pay for all dental fees charged to me for services provided. My signature below is authorization of the assignment of my Dental Insurance payment to Sweet Tooth Dentistry. If my plan denies payment of my benefits to Sweet Tooth Dentistry, I agree to pay my account in full.
Signature of Patient, Parent or Guardian: Date: Witness:I hereby authorize Sweet Tooth Dentistry to process payment to my credit card of any outstanding balance for dental treatment.
Credit Card No: CVV: Exp. Date:
Name on Card: Signature: Date: