jeffmatilskydmd.com - Patient Information

Patient Information

CONFIDENTIAL
Name:

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Birthdate

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Bus. Phone
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Social Security
Check Appropriate Box:

MinorSingleMarriedDivorcedWidowedSeparated
If Student

Full TimePart Time
Email:
example@example.com
Patient's or Parent's Employer
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse or Parent's Name
Employer
Work Phone
Please enter a valid phone number.
Whom May We Thank For Referring You?
Person to Contact in Case of Emergency
Phone Number
Please enter a valid phone number.
Relationship
Responsible Party
Name of Person Responsible for this Account
Relationship to Patient
Address
Home Phone
Please enter a valid phone number.
Driver's License #
Birthdate

MonthDayYear
Date
Financial Institution
Employer
Work Phone
Social Security #
Is this Person Currently a Patient in our Office?

YesNo
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

CashPersonal Check
Credit Card

VISAMasterCardDebit CardAmerican ExpressDiscover
I certify that I have read and understand the above information to the best of my knowledge. I understand that I am responsible to pay as services rendered. I understand that I am responsible for any fees that will acquire for legal action being taken to collect my debt. I further understand that if a payment becomes 30 days past due, delinquency at the lesser of the annual rate 18% , or the maximum allowable rate, will be due on delinquent amounts from the date the payment was due. I acknowledge that there is a fee for bounced and checks and that I may lose my rights to use checks. Our office is entitled to a minimum of 48 hours cancellation notice. We reserve the right to charge cancellation fees for missed or broken appointments.
Patient Signature

Clear
Witness Signature

Clear
Insurance Information
Name of Insured
Relationship to Patient
Birthdate

MonthDayYear
Date
Social Security #
Date Employed

MonthDayYear
Date
Name of Employer
Union or Local #
Work Phone
Please enter a valid phone number.
Insurance Company
Group #
Policy/ID #
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Much is your Deductible?
How Much Have You Used?
Max. Annual Benefit
I authorize and request my insurance company to pay directly to the dentist of dental group insurance benefits otherwise payable to me, I acknowledge that after thirty-days my account may acquire interest. After 45 days if insurance does not pay. I will be responsible for my account.
Patient Signature

Clear
Should be Empty:

Patient Information

Responsible Party

Insurance Information