RESPONSIBLE PARTY INFORMATION          

DATE:                                Responsible Party:
                                                                                           Last Name                                  First Name                                   Initial
Address:
                                          Street                                               City                         State                  Zip
Home Phone: Work Phone: SS#
I understand that when appropriate, credit bureau reports may be obtained.

Responsible Party Signature _____________________________________________

PATIENT INFORMATION              

Patient Name:
                                                       Last Name                First Name                                   Initial
Patient Address (if different than above):
                                                                           Street                                        City                         State                  Zip
Whom may we thank for referring you?
Sex   : ___ Male ___ Female Birthday: SS#
Patient Phone (if different than above): School Name/City
Employer: Work Phone:
Occupation: Length of employment:
Name of nearest relative in case of emergency: Phone:
  PRIMARY DENTAL INSURANCE    SECONDARY DENTAL INSURANCE
Employee Name:    
Address:    
Work Phone:    
Social Security No.    
Birthday:    
Plan/Union Name:    
Employer:    
Employer City/State:    
Group No.    
Carrier Name:    
Carrier Add.    

I authorize release of any information related to my claims.   I understand I am responsible for all costs of dental treatment.  I hereby authorize payment directly to the dentist of the insurance benefits otherwise payable to me.

Signature ____________________________________________ Date ________________