Patient employed by*
Whom may we thank for referring you?*
In case of emergency who should be notified?*
Person Responsible for the Account*
Relation to Patient*
Address (if different from patient)*
Subscriber S.S. #*
Assignment and Release
I, the undersigned certify that I (or my dependant) have insurance coverage with above mentioned insurance company and assign directly to Dr.Julio A. Rodriguez all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits, I authorize the use of this signature on all insurance submissions.
Responsible Party Signature *
Relationship to patient *
Dental History (Confidential)
Reason for Today's visit
Date of last dental care
Date of last dental x-ray
How often do you floss?
How often do you brush?
Please Check the Radio Button
In the past week have you taken any recreational or medicinal drugs not listed above?YesNo
If yes then what?
Please Select any Allergies you may have:
AspirinBarbiturates (sleeping pills)CodeineLocal AnestheticPenicillinSulfaOther
The Above Information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form.
Patient Acknowledgement of Receipt of the Notice of Privacy Practices
I acknowledge that i was provided with a copy of the Notices of privacy Practices, describing how my health information may be used or disclosed under the federal law. I hereby consent to the use and disclosure of my health information for the purpose and the activities under the federal privacy law. Iam aware that the Notice may be changed at any time I may obtain a revised copy by calling the offices
Patient's Name :
Signature (if minor Parent or Guardian)