911 Dentistry Welcome Form

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Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please call us at 310.552.1441 - we will be happy to help.

1. Personal Information

Date:
Birthdate:
Social Security #:
Name:
Address:
City:
State:
Zip Code:
Employer:
Occupation:
Referred By:
2. Responsible Party
Who is responsible for this account?
Name:
Relationship to patient:
Birthdate:
Driver's License #:
Social Security #:
Address:
City:
State:
Zip Code:
Employer:
Occupation:
Work Phone:
Ext:
Home Phone:
3. Telephone
Home Phone:
Work Phone:
Ext:
Cell Phone:
Where do you prefer to receive calls?
When is the best time to reach you?
Emergency contact:
Relationship:
Work Phone:
Home Phone:
Cell Phone:
4. Dental Insurance Information
Name of Insured:
Relationship to patient:
Insured's Birthdate:
Social Security #:
Employer:
Date Employed:
Occupation:
Insurance Company:
Group #:
Employee/Cert #:
Insurance Company Address:
Deductible:
Amount Already Used:
Max. Annual Benefit:
5. Additional Insurance
Name of Insured:
Relationship to patient:
Insured's Birthdate:
Social Security #:
Employer:
Date Employed:
Occupation:
Insurance Company:
Group #:
Employee/Cert #:
Insurance Company Address:
Deductible:
Amount already used:
Max. annual benefit:

6. Authorization and Release

I authorize the dentist to release any information including the diagnosis and the record of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other health practitioners.

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.


Patient or Parent if Minor	Date

7. Financial Arrangements

For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment

Cash Personal Check Credit Card
I wish to discuss the dental office's policy
Payment in full
(10% OFF patient fee/portion if paid in full at each appointment)

Phone:310-552-1441, 24-Hour Voice Mail Pager 800-605-0923
153 South Lasky Drive, Suite 5, Beverly Hills, CA 90212
Email: mark@911dentistry.com