Patient Information

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1033 E. Wilcox Ave. | P.O. Box 667| White Cloud, MI 49349 | |231-689-6651, Fax: 231-689-5820

Patient Information

Date _____________

Patient Name ________________________________________________ Birthday ______________ Age _____________

First Middle Last

Sex: M F Social Security #: ________________________
Marital status: Minor Single Divorced Married Spouse’s name: _________________________________
Home Address: __________________________________________________________________________________________

Street City State Zip

Home Phone: ___________________________ Work Phone: __________________ Cell Phone:__________________
E-Mail Address: ____________________________ Employer: ____________________________________________________
How Did You Hear About Our Office: ________________________________
Parent/Guardian of patient (if under 18 yr of age)
Person Responsible for account :______________________________ Relationship: __________________________

Social Security #: ______________________________ Birthday:______________________________

Home Address: ___________________________________________________________________________________

Street City State Zip

Policy Holder: _________________________________ __________________ __________________

Name DOB Social Security

Dental Insurance: _________________________________ __________________ __________________

Company Subscriber ID # Group #

Secondary Insurance: _________________________________ __________________ __________________

Company Subscriber ID # Group #

Employer: _______________________________________________ Work Phone: __________________________________
We bill your insurance as a courtesy. If insurance does not pay within 60 days, we reserve the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is important that you recognize the insurance you have as a legal contract between you and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
Emergency Contact: _________________________________________________________________________________________

Name Relationship Phone Number

I understand that payment is due at the time of service. I will pay today by: Cash Check Credit Card Care Credit
I verify that the preceding information is true. I authorize the release of information to my insurance company. I will allow John F. Schondelmayer, D.D.S. and his associates to discuss my conditions with my physician(s) and to request medical information from them. I authorize the office of John F. Schondelmayer, D.D.S. to obtain and verify a credit report. I also agree to act in accordance with My LifeCare Dental’s Patient Expectations.
Patient Signature: ___________________________________________________ Date: ________________

(Parent/Guardian if minor)

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