Karl L. Hoffman DDS.....



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To speed up the process of gathering information for our new patients, we offer this online form.
1.Personal Information
Date:
Birthdate:
Social Secuity Number:
Name:
Wishes to be called:
E-Mail Address:
I am:
I am:
Address:
City, State, Zip:
Employer:
Occupation:
Reffered By:

2.Responsible Party
Who is responsible for this account?
Name:
Relationship to patient:
Birthdate:
Drivers License #
Social Security #
Address: (if different)
City: State:
Zip:
Employer:
Occupation:
Phone Number: Work: Ext:
Home:


3.Patient Phone
Home Phone:
Work Phone:
Cell Phone:
Where do you prefer to receive calls?
When is the best time to reach you?
Time:
Days:
In the event of an emergency, whom should we contact?
Name
Relationship:
Work #
Home #:
4.Dental Insurance Information
Primary Insurance
Name of Insured:
Relationship to patient:
Insured's Birthdate:
Social Security #:
Employer:
Insurance Company:
Insurance Co. Address:
Address 2:
Deductible:
Amount already used:
Max. Anual Benefit:

Additional Insurance
Name of Insured:
Relationship to patient:
Insured's Birthdate:
Social Security #:
Employer:
Insurance Company:
Insurance Co. Address:
Address 2:
Deductible:
Amount already used:
Max. Anual Benefit:

5.Authorization & Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinationrendered to me or my child during the period of such Dental care to third party payers and/or other health pratitioners

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 the actual bill of services.I agree tobe responsible for payment of all services rendered on my behalf or my depentents.


I agree: I do not agree:
Date:

6.Financial Arrangements
For your convenience, we offer the following methods of payment.
How do you prefer to pay?:

Cash:   Personal Check:   Visa:   Master Card:   
I wish to discuss the office's policy:   



Late Charges

If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owedwill be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costsand resonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

     

Thank you for filling out this form completely. The information you have provided will help us serveyour dental healthcare needs more effectively and efficiently. If you have any questions at anytime,please ask, we are always happy to help.






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