3705 Beacon Ave, Suite 101, Fremont CA 94538|510-794-9122
FremontFamilySmiles.com |
Welcome to our practice!
Patient Information
Patient’s Name: ______Today’s Date: ______
I prefer to be called by: ______Date of Birth: ______
Home Address: ______City, State, Zip: ______
Cell Phone: ______Home Phone: ______Best time to contact you? ______
Email: ______How did you hear about us? ______
Employer: ______Social Security #: ______
Marital Status: □ Single □ Married □ Separated □ Divorced □ Widowed
Emergency Contact Name and Phone Number:______
Please Circle which method you prefer to confirm your appointments: Text Email Phone
Insurance Information
Do you have insurance that may cover any part of our Professional Services? (Y/N): ______
Name of Subscriber: ______Relation to Patient: ______
Home Address (if different from patient): ______
City, State, Zip: ______Date of Birth: ______
Home Phone: ______Cell Phone: ______
Email: ______Best time to contact you? ______
Employer: ______Social Security #: ______
Primary Dental Insurance Info
Insurance Plan Name: ______Insurance Phone #: ______
Group / Policy #: ______Subscriber ID #:______
Insurance Address: ______
Secondary Dental Insurance Info
Insurance Plan Name: ______Insurance Phone #: ______
Group / Policy #: ______Subscriber ID #:______
Insurance Address: ______
I understand that dental procedures are not an exact science; therefore, any given procedure may not succeed. Although dental therapy has a high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed.
I also acknowledge full responsibilityfor the payment of all services performed. I agree to pay my portion in full at or before completion, unless other specific arrangements are made.
I understand that dental insurance companies sometimes pay a percentage of dental therapy and this percent will vary from dental plan to dental plan andthat I am provided an approximation of insurance coverage but full payment is my responsibility.
I authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. I also authorize release of any information necessary to process dental insurance.
I understand the Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient.We require that you give our office 48 hours noticein the event that you need to reschedule your appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A fee of $50.00 will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility.
Signature of Patient or Guardian: ______Date: ______