Bradford Family Dentistry

Bradford Family Dentistry Family, Cosmetic, Implants, & Sedation

Today"s Date:

Date

Patient"s Name

Address

City

Province

Postal

Email Address

Spouse"s or Patient"s Name (If patient is a minor)

Sex:

Male Female

Patient Is:

Minor Married Single Student Widowed

Date of Birth

Date

Home Phone

Cell Phone

Employed (Select One)

Full Time Part Time Other

Employer Name

Employer Phone

Emergency Contact

EMRG. Cont. Phone

Whom May We Thank for Referring You?

Responsible Party Information:

This is the account guarantor and this person MUST sign below

Name

Relation to Patient

Address

City

Province

Postal

Birth Date

Date

SIN #:

Sex:

Male Female

Home Phone

Cell Phone

Employer Name

Employer Phone

Dental Insurance Information:

Please complete information even if you"ve presented a card to us

Name of Policy Holder

Relation to Patient

Address

Policy Holder"s Birth Date

Date

SIN#/Identification #

Group or Policy #

Policy Holder"s Employer

Insurance Company

Insure. Co. Phone

Do you have secondary dental insurance coverage?

Yes No

If yes, please present your card at your first visit.

Financial Agreement:

* I understand payment is due at the time of service. If I have dental insurance, I agree to pay my estimated out-of- pocket expenses at the time of treatment. * I understand all balances over 60 days are subject to a 1.5% per month billing cycle. * I agree to be responsible for all charges which remain unpaid by my insurance after 45 days.

Payment Options:

* Cash, Check or Credit Card at time of service * Auto monthly deduction from credit or debit card * Extend Payment Plan (OAC) * Payment in full prior to treatment: 5% discount (cash/check only)

I hereby authorize and direct Bradford Family Dentistry, as assisted by other dentists and auxiliaries, to perform any necessary dental treatment.

All patients under the age of 18 must have a parent or legal guardian present for all scheduled appointments.

__________________________________ _____________________

Patient/Guardian Signature (Account Guarantor) Date

[Signature Completed At First Office Visit]