Shek Patient Information

Today's date

MonthDayYear

Patient's Name*

First NameLast Name

Age

Patient's birthday

MonthDayYear

MaleFemale

If patient is a minor, give name of parent or legal guardian

Relationship

Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

For how long?

OwnRent

Patient is:

E-mail

Driver's license number

Social security number

Res. phone

Area CodePhone Number

Bank

Account number

How long?

Call phone

Area CodePhone Number

Employed by:

How long?

Occupation

Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business phone

Area CodePhone Number

Spouse's name

First NameLast Name

Driver's license number

Social security number

Employed by

How long?

Occupation

Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business phone

Area CodePhone Number

Name of nearest relative not living with you

Relationship

Complete address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Residence phone

Area CodePhone Number

Name of physician

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone

Area CodePhone Number

Former dentist

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone

Area CodePhone Number

Why are you changing dentist?

Purpose of appointment

Do you wish to speak to the doctor privately?

YesNo

Is this office visit for Emergency Dental Care?

YesNo

If yes, explain

School children attend

Whom may we thank for referring you?

Person responsible for this account

Relationship

Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell phone

Area CodePhone Number

Preference of payment

Cash on day of paymentVisaState AidMastercard

If Visa, State Aid or Mastercard, please enter number

If Visa or Mastercard, please enter expiration date

Name of insurance company (primary insurance)

INsured person's name

Birthdate

MonthDayYear

Relationship

Social security number

Name of group dental plan

Group number

Plan number

Name of union

Local

Name of insurance company (secondary insurance)

Insured person's name

Birthdate

MonthDayYear

Relationship

Social Security number

Name of group dental plan

Group number

Plan number

Name of union

Local

As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incured in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for in cash at the time services are performed.

I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment of all dental services. If I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collectionsto my account. However this dental office cannot render services on the assumption that charges will be paid by an insurance company.

Asignemtn of Insurance: I hereby authorize my insurance company to pay directly to my dentist benefits accruing to me under my policy. A service charge of 1 1/2 percent per month (18 percent per annum) (but in no event more than the maximum rate permissible under state law) will be charged on the unpaid principal balance on all accounts not paid within 60 days of treatment date.

I understand that the fee estimate listed foe this dental case can only be extended for a period of six months from the date of the patient's examination. In consideration of the professional services rendered to me, or at my request, by the Doctor and/or his staff, I agree to pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within the time pf payment thereof. Additionally, I agree that a waiver for any breach of any term or condition hereunder shall not constitute a waiver or any further term or condition. I further agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney's and/or collection fees.

I grant my permission to you, or your assignment to telephone me at home or at my work to discuss matters related to theis form.

I have read the above conditions of treatment and agree to their content.

Signature

Date

MonthDayYear

Patient Information

Financial Information

Terms and Conditions