Welcome to Siebenthaler Dental Center

Please take a few minutes to fill out this form as completely as you can.
If you have any questions, well be glad to help you.
PATIENT INFORMATION

Name________________________________________________________________________________________
Last

Gender: [ ] M [ ] F

First

MI

Marital Status: S / M / D / W

(Preferred Name)

DOB: ____________________

Email: _______________________________________ SS#___________________________

Address:
Street__________________________________________________________ Apt # _______________
City______________________________ State__________ Zip__________________
Phone:
Home ( )____________________ Work (
) ____________________ Wireless (
)____________________
Place of Employment:_______________________ [ ] FT [ ] PT [ ] Retired [ ] Not Employed [ ] Student
Person responsible for account: [ ] Self [ ] Other:_______________________________
If other; SS#:____________________________
How did you hear about us? [ ] From another patient [ ] Yellow Pages [ ] Website [ ] Other
_____________________________________________________________________________________________
(If someone referred you here, please write down his/her name so we can send a thank you.)
INSURANCE POLICY 1

[ ] None
Please present insurance card to receptionist
Your relationship to person insured: [ ] Self [ ] Spouse [ ] Child

[ ] Other_________________________

Insurance company ____________________________________________________Group #_________________

Name of person insured_______________________________________________________
Address (if different)___________________________________ City_______________ State_____ Zip_________
DOB: __________________ SS #_______________________________ Phone (
) ______________________
Names of other dependents covered under this plan___________________________________________________
INSURANCE POLICY 2

Please present insurance card to receptionist

Your relationship to person insured: [ ] Self [ ] Spouse [ ] Child

[ ] Other_________________________

Insurance company_____________________________________________________Group #__________________

Name of person insured_______________________________________________________
Address (if different)___________________________________ City_______________ State_____ Zip_________
DOB:_____________________ SS #____________________________ Phone (
)______________________
Names of other dependents covered under this plan___________________________________________________
(Continue on back)

FINANCIAL AGREEMENT

* For my convenience, this office may release my information to my insurance company and receive payment directly
from them.
* If my insurance does not pay as expected, I understand that I will be responsible for any outstanding balance.
* Patient portion will be due at the time of service. All major credit cards and personal checks are accepted.
* I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time.
* If sent to collections, I agree to pay all related fees and court costs.
* I will pay a fee for appointments broken without 24 hours notice.
* Treatment plans may change, and I will be responsible for the work actually done.
Signature__________________________________________________________ Date______________________
NOTICE OF PRIVACY POLICIES

I have been given the opportunity to read and consider the contents of the Notice of Privacy Practices (HIPPA).
I understand that I am giving my permission to the use and disclosure of my protected health information in order to
carry out treatment, payment activities and healthcare operations. I also understand that I have the right to revoke
permission. This office is paperless and digital photos will be taken for medical identification purposes only.
Signature__________________________________________________________ Date_______________________
MEDICAL HISTORY

Emergency Contact_________________________ Phone_________________ Relationship____________________

List all the medications or drugs you are now taking:
List all the medications or drugs you are allergic to:
[ ] None______________________________________
[ ] None_______________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
List any medical conditions you may have including: anemia, asthma, bleeding problems, cancer, diabetes, epilepsy,
glaucoma, heart trouble (stents and pacemaker), hepatitis, herpes, high/low blood pressure, HIV+/Aids, joint
replacement, kidney disease, liver disease, pregnancy, psychiatric treatment, sinus trouble, stroke, or ulcers.
[ ] None_______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________
*Does the patient require a pre-medication? Y / N
Unusual reaction to dental injections? _____________________________________________________________
Are you experiencing any dental pain? Y / N
Name of former dentist_________________________________________ City/State________________________
Date of last cleaning and exam_________________________

Patient Signature_____________________________________________________Date______________________
Parent/ Legal Guardian (if patient under 18 years of age)
Print Name ______________________________________________ Relationship: __________________________
*Please note: If patient is under 18 years of age,
this office will need verbal permission to treat at every appointment*