CONFIDENTIAL INFORMATION QUESTIONNAIRE
EMERGENCY CONTACT INFORMATION

PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)

REQUEST FOR CONFIDENTIAL COMMUNICATION

AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION:

Contact me at home YesNo
Contact me via cell phone YesNo
Contact me at work YesNo
Contact me via email YesNo
Leave messages on my home voicemail/answering machine YesNo
Leave message on my cell phone voicemail YesNo
Leave messages on my work voicemail/answering machine YesNo
INSURANCE AND FINANCIAL INFORMATION
Insurance coverage YesNo
Secondary Insurance coverage YesNo
RELEASE INFORMATION

YOU MAY DISCUSS MY HEALTHCARE WITH:

Health Care Providers YesNo
Insurance Companies YesNo
CONFIRMATIONS

DO YOU PREFER A CONFIRMATION CALL:

No, it is unnecessary
Yes, it is a helpful reminder
ASSIGNMENT & RELEASE

I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations and/or presentations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

Date: 
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