Patient Information Sheet Template
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1patient information sheet
titLe (mr., mrs., ms., Dr.) first name _______________________________ middle initial _________ Last name ______________________________________
o
o
I prefer to be called _____________________________ Sex:
Male
Female
Drivers License No: ________________________________________
Date of Birth __________________________________Age _____________ Social Security No: ______________________________________________________
Street ________________________________________________________________________________________________________________________________
City _________________________________________ State_____________ Zip Code ___________________Email ______________________________________
Home Telephone (_____) _______________________ Bus. Telephone (_____) _________________________Spouse’s Name _____________________________
o
o
o
Cellular No (_____) _____________________________ Referred By:
Yellow Pages
Red Book
Dr. ________________________________________
o
o
Patient __________________________________________________________
Other ___________________________________________________________
responsible party information (if different than above)
social security no._______________________________________
name __________________________________ home telephone (_____) ______________________ Date of Birth _____________________________________
street __________________________________ City_________________________________________ state _____________Zip Code _____________________
employer __________________________________________________________ position ___________________________________________________________
Bus. telephone (_____) ______________________________________________ Cellular no (_____) __________________________________________________
o
o
o
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employed:
full time
part time
retired
homemaker
in case of emergency:
name _______________________
o
o
o
o
o
marital status:
married
Divorced
Legally seperated
Widow
single
phone _______________________
o
o
student:
full time
part time
school name/City/state _____________________________
relationship _________________
Patient emPloyer information
employer ____________________________________________________________________ phone (_____) ____________________________________________
street ______________________________________________ City ______________________________________state ____________ Zip ___________________
position ______________________________________________________________________________________________________________________________
Primary insurance information
secondary insurance information
Name of Insured: ____________________________________________
Name of Insured: ____________________________________________
Insured Date of Birth: _________________________________________
Insured Date of Birth: _________________________________________
Insured Social Security: _______________________________________
Insured Social Security: _______________________________________
Patient Relationship to Insured: _________________________________
Patient Relationship to Insured: _________________________________
Insured Employer: ___________________________________________
Insured Employer: ___________________________________________
Ins. Company: ______________________________________________
Ins. Company: ______________________________________________
Ins. I.D. #: _________________________________________________
Ins. I.D. #: __________________________________________________
Insurance Policy of Office
our professional treatment is rendered to you, not to the insurance company. You, therefore, are directly responsible to
us for payment for treatment. As a courtesy to you, we will fill out and submit claims to your insurance company. You will
then be reimbursed by your insurance company according to the terms of your policy.
Billing Policy
fees are openly discussed prior to treatment and we request payment for service to be made at time of treatment. if the
balance on your account is not paid in full within 60 days from either you or your insurance company, you will be as-
sessed a finance charge of 18% per annum computed monthly at 1.50% and not to exceed that amount allowed by law.
if your account is placed in the hands of an agency for collection, you will be responsible for collection fees. if it becomes
necessary to file suit against you to recover an outstanding balance, you will be responsible for collection fees, court
costs and attorney fees.
i understand that the administration of local anesthetic may cause an untoward reaction or side effect, which may in-
clude, but not limited to, bruising, hematoma; cardiac stimulation; muscle soreness; and temporary or rarely, permanent
numbness. i understand that occasionally needles break and may require surgical retrieval.
signature _____________________________________________________________________(seaL)_Date ________________
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