1. About You
Today’s Date:
Patient’s name:
If child, name of guardian:
I like to be called:
Home address:
If yes, please provide their name(s):
Your employer:
Occupation:
Birthday:
How did you hear about Shelburne Village Dental?
2. Dental Insurance
If yes, please provide the following information:
Group/plan #:
Subscriber ID #:_
Employer name:
Their name:
Their birthday:
Their employer’s name:
Dental insurance company:
Group/plan #:
Subscriber ID #:
3. Telephone/Email
Home Tel. #
Work Tel. #:
Cell Tel. #
Email:
In the event of an emergency, is there someone who lives near to you that we could contact?
4. Medical History
Family physician’s name:
Tel. #:
Approximate date of your last visit:
Week #:
2. I hereby authorize the doctor or designated staff to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of (name of patient)'s dental needs.
3. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and employ such assistance as
required to provide proper care
4. I agree to the use of local anesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents
embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
5. Payment is due in full on date of service with the following payment options: CASH, VISA, MASTERCARD, INTERAC
Our office is equipped to submit insurance claims electronically if we have your correct information. (Note: Not all insurance companies do
electronic claims.)
PLEASE DO NOT HESITATE TO ASK OUR STAFF SHOULD YOU HAVE ANY QUESTIONS REGARDING PAYMENT.
6. Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require 48 hours notice,
otherwise it will be necessary to charge for time lost.
7. I authorize release, to my dental benefits plan administrator & the CDA, information contained in claims submitted electronically. I also
authorize the communication of information related to the coverage of services described to the name dentist. This authorization will
continue in effect until the undersigned revokes the same.
I UNDERSTAND AND AGREE TO THE POLICIES LISTED ABOVE.
Patient’s Name:
Dentist:
Parent/Guardian’s Name:
Relationship to Patient:
Signature of Patient, Parent or Guardian:
Date:
Send
