Thank you for your Form Submission. Please print this page for your records.
PATIENT INFORMATION
Patient Name
          
Spouse's Name
Sex
Male      Female
Spouse's Birthdate
Date of Birth
  Age
Spouse's Soc. Sec. #
Street Address
Spouse's Employer
City
ST Zip
Spouse's Work Phone
Home Phone
Are you a full-time student?
Cell Phone
Name Of School
Email
If patient is a minor, we need:
Soc. Sec #
Name of Father
Occupation
Father's Employer
Employer
Father's Work Phone
Work Phone
Name of Mother
Referred by
Mother's Employer
Single    Married    Separated    Divorced    Widowed
Mother's Work Phone
       
INSURANCE INFORMATION
Dental Insurance Info (Primary Carrier)   If you have double Dental Insurance Coverage, complete this for the 2nd coverage.
Policyholder's Name
Policyholder's Name
Policyholder's Employer   Policyholder's Employer
Insurance Company   Insurance Company
Insurance Co. Address   Insurance Co. Address
Policyholder's Soc. Sec. #   Policyholder's Soc. Sec. #
Group ID#   Group ID#
Date of Birth   Date of Birth
         
IN EVENT OF EMERGENCY   FINANCIAL POLICY

We make every effort to keep the cost of your dental care to a minimum. Therefore, payment is expected at the time of your visit. Payment may be made by check, cash or credit card. We accept Visa, MasterCard, Discover and Care Credit®.

We are a participating provider with several insurance companies and will file your insurance if you furnish us with all the necessary information. However, you will still be expected to pay your deductible and co-pay at the time of your visit.

In a single parent family or in divorce situations where children are involved, the parent bringing the child to the office for treatment will be responsible for payment.

Who should we contact?  
Relation  
Home Phone #  
Work Phone #  
Cell Phone #  
Who is your Medical Doctor?  
     
CONSENT
The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I or we agree to be financially responsible for any unpaid balance due to the health care provider for services rendered. I or we grant permission to the health care provider, its agent or assigns to discuss our account and release any information with any third party tin order to assist in the payment of any balance due, or otherwise verify personal information provided. Also, it is understood and agreed that the health care provider reserves the right to assess a monthly finance charge, in accordance with Arkansas law, to any unpaid balance due. Further, it is agreed that should the healthcare provider determine that it is necessary to employ a collection agency to recover any unpaid balance owed, I or we agree to pay any and all collection fees and costs expended to effect recovery, with such collection fees to be 50% of the unpaid balance due in addition to collection fees. I or we agree to pay attorney fees and court costs should my unpaid account require legal action. 		 
 
 
 
         
Patient Signature
(If minor, Parent or Legal Guardian)
(If Submitting on-line, please sign paper on next visit to our office.)		   Date
       

 

 

 

      
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and Mail or bring in to our office at
550 Chesnut St . , Conway AR  72032  (Corner of Chesnut & Deer St.)