FORM

Patient Information

Dental Insurance

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with __________________________________________________ and assign directly to

Dr.

If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the gate signed below.

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT  (Specify someone who does not live in your household.)

DENTAL HISTORY

Place a mark on "yes" or "no" to indicate if you have had any of the following:

HEALTH HISTORY

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (doxfonfluramine).

Place a mark on "yes" or "no" to indicate if you have had any of the following:

WOMEN:

MEDICATIONS