1Contact Information2Financial Information3Dental Release Information4Signature: Your rights and permissions Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient's Name First Last If child, parent's name First Last Filing Status Married Single Minor Domestic Partner Gender* Male Female Non-binary / Preferred Pronoun Patient Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address*Phone*BirthdateSocial Security NumberPlace of EmploymentWork AddressHas any member of your family been treated in our office? Yes No If yes, family member's name who was treatedHow did you find about our office? Anyone we can thanks?*Please send me electronic appointment reminders via: Email We will never disclose your email address to anyone. Text Message We do not charge for this service. Your carrier's data and messaging rates may apply. Minor Child - May need to complete both blocks for parent information Adults - Complete primary insured Duel Coverage? Also complete secondary insured Dental Insurance 1st CoveragePolicyholder name First Middle Last Policyholder address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policyholder phone numberPolicyholder date of birth MM slash DD slash YYYY Relationship to PatientEmployerName of insurance company/addressSocial Security NumberSubscriber numberPolicyholder GROUP ID numberDental Insurance 2nd Coverage (if different then primary)Policyholder name First Middle Last Policyholder address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policyholder phone numberPolicyholder date of birth MM slash DD slash YYYY Employer nameName of insurance companyPolicyholder ID numberPolicyholder GROUP ID number AuthorizationAuthorization*I hereby authorize payment directly to South Waterfront Dental of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize South Waterfront Dental to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health professionals ConsentFinancial Agreement & Cancellation Policy In order to assist you in making payments for your dental treatment, several options are available. Payments may be made by cash, check, credit card (VISA, MasterCard or Discover) or Care Credit. We reserve the right to charge a $25.00 fee for all checks returned for non-sufficient funds. Unless other arrangements have been made, your balance is due at the time services are rendered. If you have dental insurance, as a courtesy, we will bill your insurance carrier directly. Dental insurance rarely covers 100% of services rendered; therefore please be prepared to pay your co-pay at each visit. South Waterfront Dental is happy to provide an estimate for your co-pay prior to your visit. This is an estimate only and you will be responsible for any amounts not reimbursed by your dental insurance. Scheduled appointments are reserved specifically for you. If you need to change an appointment, please contact the office with at least 48 hours notice. There will be a $25.00 fee for appointments cancelled without 48 hour notice. There will be a $50.00 fee for not showing for a scheduled appointment. We realize that time is very important to you, and we make every effort to stay prompt. We ask that you have the same consideration by being on time for your appointments. Please do not hesitate to ask any questions you may have concerning office policies. We welcome open communication with you and wish to develop a relationship of friendship and trust. Our goal is to meet your dental needs while offering you the most comfortable and enjoyable dental experience. Patient's signature*By typing your full name here, you are electronically signing this document. First Last Please select today's date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
