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Adult New Patient Form

Thank you for selecting our dental health care team! We will strive to provide you with the best possible dental care. To help us meet your dental health care needs, please fill out this form Completely. If you have any questions or need assistance, please ask us we will be happy to help.

Patient Information (confidential)

    Marital Status:

   

   

  Type of Student:

 

   

 

 

Responsible Party

 

   

   

   

 

Is this person currently a patient in our office?: YesNo

For you convenience, we offer the following methods of payment. Please check the option you prefer.
CashPersonal CheckVisaMastercardI wish to discuss the office's payment policy

Insurance Information

   

 

 

   

   

   

   

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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When you've finished this form please fill out the Adult Health History Form.

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Bedford Family & Laser Dentistry