New Patient Application

New Patients Please complete the following. The information will be submitted electronically to Hagen Dental Practice.

Patient Information

Emergency Contact

General Information
Health History Information Yes No
Reason:

Do you currently have (or have a history of) any of the following:

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Insurance Information (Optional)
Verification

Before your next appointment, we’ll ask you to verify this information and sign a form, indicating:

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.