* = required field Personal Information *Name: *Email: Date of Birth: / / S.S. Number: Marital status: single married Street Address: City: State: Zip Code: Phone: Person responsible for paying account: Address & phone number of that person if different than above: Dental insurance company: Name of insured: S.S. # of insured: Insured place of employment: Patient Information Firm: Business Address: Business City/Zip Code: Business Phone Present Position: Spouse Information Firm: Business Address: Business City/Zip Code: Business Phone: Present Position: Referred by: Last dental visit: Purpose of this visit: I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance, for myself, or above named patient, unless other financial arrangements are approved. I also agree to pay for all costs of collection, including attorney fees, and court cost, should additional means of collection be required. In addition, my signature on this form is my acknowledged authorization for the doctor to seek a credit report if credit is extended.
Copyright © 1999 by Lawrence W. Hagen, II, D.D.S. 4998 Glenway Avenue • Cincinnati, Ohio 45238 Phone: (513) 251-5500 • Fax: (513) 251-0687 Email: hagendds@aol.comHagen DDS Home This site hosted by Electronic Art
