Bradford Family Dentistry

Bradford Family Dentistry Family, Cosmetic, Implants, & Sedation

Today"s Date:

- Month - Day Year
Date
Patient"s Name
Address
City
Province
Postal
Email Address
Spouse"s or Patient"s Name (If patient is a minor)
Sex:

Male Female
Patient Is:

Minor Married Single Student Widowed
Date of Birth

- Month - Day Year
Date
SIN #:
Home Phone
Cell Phone
Employed (Select One)

Full Time Part Time Other
Employer Name
Employer Phone
Emergency Contact
EMRG. Cont. Phone
Whom May We Thank for Referring You?
Responsible Party Information:
This is the account guarantor and this person MUST sign below
Name
Relation to Patient
Address
City
Province
Postal
Birth Date

- Month - Day Year
Date
SIN #:
Sex:

Male Female
Home Phone
Cell Phone
Employer Name
Employer Phone
Dental Insurance Information:
Please complete information even if you"ve presented a card to us
Name of Policy Holder
Relation to Patient
Address
Policy Holder"s Birth Date

- Month - Day Year
Date
SIN#/Identification #
Group or Policy #
Policy Holder"s Employer
Insurance Company
Insure. Co. Phone
Do you have secondary dental insurance coverage?

Yes No
If yes, please present your card at your first visit.
Financial Agreement:
* I understand payment is due at the time of service. If I have dental insurance, I agree to pay my estimated out-of- pocket expenses at the time of treatment. * I understand all balances over 60 days are subject to a 1.5% per month billing cycle. * I agree to be responsible for all charges which remain unpaid by my insurance after 45 days.
Payment Options:
* Cash, Check or Credit Card at time of service * Auto monthly deduction from credit or debit card * Extend Payment Plan (OAC) * Payment in full prior to treatment: 5% discount (cash/check only)
I hereby authorize and direct Bradford Family Dentistry, as assisted by other dentists and auxiliaries, to perform any necessary dental treatment.
All patients under the age of 18 must have a parent or legal guardian present for all scheduled appointments.
__________________________________ _____________________
Patient/Guardian Signature (Account Guarantor) Date
[Signature Completed At First Office Visit]
Should be Empty: