COAST DENTAL
1976 College Boulevard Oceanside, CA 92056 (760) 758-9400

Patient Name Social Security Number Home Phone
(    )
Home Address City, State, Zip Birth Date
   /    /
Marital Status
o Single   o Married   o Divorced  o Separated		 Gender
o Female o Male		 Driver’s License #
Primary Ins. Company Group #
 Subscriber
Secondary Ins. Company Group #
 Subscriber

RESPONSIBLE PARTY

Name Social Security Number Home Phone
(      )
Home Address City, State, Zip Birth Date
Marital Status
o Single o Married   o Divorced  o Separated		 Relationship to Patient Driver’s License #
Responsible Person’s Employer Occupation Work Phone
(      )
Business Address
 City, State, Zip  
Spouse’s Name Social Security Number Birth Date
    /       /
Spouse’s Employer Spouse’s Occupation Spouse’s Work #
(     )
Spouse’s Business Address
 City, State, Zip

  

How did you hear about our office?
o Referred by a friend o Yellow Pages o Relative o Insurance Plan o Welcome Wagon
o Other____________ o TV/Radio Ad o Newspaper Ad o Direct Mailing o Sign by Building
If you were referred, whom may we thank for referring you?_____________________________________________________________

CONSENT
I will answer all health questions to the best of my knowledge._________ (initial)
After explanation by the doctor, I hereby authorize the performance of dental services upon the above named patients and whatever procedures that the judgment of the doctor may dictate in order to carry out these procedures.  I also authorize and request the administration of any anesthetics and x-rays, as may be deemed necessary and advisable by the doctor.
_______________________________________________     ___________________________________________
Signature                                                                                   Date                                  Relationship to Patient

AGREEMENT TO PAY
I agree to pay for all services rendered.  In the event that payment is not made within thirty (30) days of receipt of statement, a service charge at the legal rate may be added to the past due balance.  If a collection agency services are required, I further agree to pay for all legal fees and costs incurred in connection therewith.  Service charges not paid when due shall be added to and become part of the principal and bear like interest until paid.  I also understand that in order to collect my debt, by credit history may be checked through the use of my Social Security number or any other information I have given you.  I understand that any and all fees incurred for dental treatment are my total and ultimate responsibility, regardless of any insurance I may have.  In the event that my insurance does not provide benefits or provides a reduced benefit, I will be financially responsible to pay up to the agreed upon fee schedule.
Payment Preference: o Cash/Check on day of treatment    o Credit Card   o Debit Card
_______________________________________________     _____________________________
Signature                                                                                   Date

There may be a charge for any missed appointment or appointments not cancelled 24 hours before the appointment time.