Patient Information Form

Patient Information Form

Patient Information Form

Patient Information Form

Patient Information Form

About Cossich Family Dentistry

Cossich Family Dentistry provides the highest quality, compassionate eye care to ensure your family enjoy a long, happy, and healthy life.

Patient Information

Date
Name:
Social Security #
Address
Address
Birthdate
Telephone
Telephone
Name of Employer
Address
If Full Time Student, School Name
If Full Time Student, School Name
Grade
Person Responsible for Account – Please Check One:

Insurance Information

Minor Child: May need to complete both boxes for parent information.
Adults: Complete side labeled Primary Insured .
Dual Coverage: Complete both boxes.

Primary Insured

If no insurance, complete for responsible party
Name
Address
Contact
Birthdate
Relationship to patients
Employer
Dental Ins. Co.
SS #
Subscriber #
Group #

Secondary Insurance

Name
Address
Contact
Birthdate
Relationship to patients
Employer
Dental Ins. Co.
SS #
Subscriber #
Group #

Person to Contact In Case of Emergency

Name
Address
Telephone
Has any member of your family ever been treated in our office?
Whom may we thank for referring you to our office?

Authorization

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office 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 payors and/or other health professionals by any method, including electronic transfer.
Date
State/Driver’s License #

Method of Payment

Responsible party currently has an account with office
Card #
Exp. Date
I wish to discuss the Dental Office’s Financial Policy

SERVICE CHARGE

If I do not pay the entire new balance within ____days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of _____% per month (or a minimum charge of $_____for a balance under $_____) which is an annual percentage rate of ____% applied to the last month’s balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs (currently $25 per outstanding account) and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.