HTML Preview Dental Medical History Form page number 1.
904.262.8409
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www.CarlsonDentalGroup.com
Bartram Office Riverside Office
13241 Bartram Park Blvd. 501 Riverside Ave.,
Bldg. 1700 Suite 104
Jacksonville, FL 32258 Jacksonville, FL 32202
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Condential Dental and Medical History
Patient’s Name _____________________________________________________ Age_______ Date of Birth ___________________
Address __________________________________________ City, State, Zip______________________________________________
Home Phone ______________________________________________ Cell ______________________________________________
Work Phone ______________________________________________ E-mail _____________________________________________
Best Contact:
EMAIL CELL TEXT HOME
Best Time to Reach You: _______________________________________________
SS# ___________________________________________________ Marital Status:
SINGLE MARRIED WIDOWED DIVORCED
Employer ________________________________ Employer Address ___________________________________________________
Spouse’s Name __________________________________ Spouse’s Phone: (Work) ____________________ (Cell) _________________
Emergency Contact ________________________________ Relation ____________ Emergency Phone _______________________
Do you have dental insurance?
YES NO
If YES, Insurance Carrier’s Name ____________________________________________
Group # _______________________ Phone _______________________ Subscriber’s Name _______________________________
Relation to Patient __________________ Subscriber’s SS# ________________________ Subscriber’s Date of Birth ______________
Employer/Co. Name __________________________________________________ Phone __________________________________
Employer/Co. Address, City, State, Zip _____________________________________________________________________________
Insurance Carrier Address,City,State,Zip ___________________________________________________________________________
HOW DID YOU HEAR ABOUT US ? ______________________________________________________________________________
Would you like to receive appointment reminders via text message?
YES NO
Would you like to become friends with Carlson Dental Group on facebook.com to receive special offers?
YES NO
OFFICE POLICY REGARDING INSURANCE: Your dental insurance is a contract between you, your employer, and the insurance company. We are
not a party to that contract. The responsibility of payment ultimately lies with the patient, not the insurance company. As a courtesy, we will file
your claim on your behalf. I understand that I am required to pay my “Estimated Patient Portion” and any deductible due, to Carlson Dental Group
at the time of my visit. Failure to provide our office with all the information necessary to file your insurance claim will require full payment at the
time of service. Any portion of treatment that the insurance does not cover is the patient’s responsibility. A statement will be sent to the patient for
any balance which is not paid by the insurance company. I hereby authorize the release of any dental information that is needed to file my insurance.
I consent to treatment for myself/family under 18 years old. I have read the above statements and understand that I am responsible for payment in
full after (45) days of my treatment, regardless of any delay in payment(s) by my insurance company. I understand that a 1.5% per month late charge
may be added to my account for any overdue balance that is my responsibility.
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