Unveiling Timeless Smiles in Shelton, CT: Where Tradition Meets Precision With Dr. Maria Smith

PATIENT NAME:

HEIGHT / WEIGHT / AGE:

NAME OF DENTIST:

NAME OF PHYSICIAN 

REFERRED BY:

IN THE FOLLOWING QUESTIONS, PLEASE SELECT YES OR NO, WHICHEVER APPLIES.  YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL. 

Please select any of the following which you had or have at the present:

To the best of my knowledge, all of the above answers are true and correct.  If I ever have any change in my health or medicines, I will inform the doctor at my next appointment. 

DOB / Gender:

Mailing Address:

Cell phone / Other phone:

Employer:

Person financially responsible for the bill:

Student and/or Minor Information

IF STUDENT OR MINOR, PLEASE COMPLETE THE INFORMATION BELOW

School / Grade:

Insurance Information

Dental Insurance

Name of insured

Address

DOB / ID #

Address

Medical Insurance

Name of insured

DOB / ID #

Payment Information

Conclusion

TO ALL OUR PATIENTS: 

Insurance is a method for reimbursing patients and not a substitute for payment. As a courtesy to our patients, the staff will work with you and help determine your benefits. Also, we will complete and submit all insurance claim forms. Payment (that which is not covered by insurance) is expected at the time of service. All accounts 30 days past due (after all insurance claims are processed) will be assessed an 18% annual (1.5% per month) finance charge. 

I authorize the release of any medical information necessary to process this claim and authorize payment of insurance benefits to Dr. Lee McNeish. I certify that the above information is correct and understand that I am financially responsible for all charges.