______Use of Bisphoshponates

Date: ______________________________20_____________ Patient Name: _____________________________________ Address: __________________________________________ _________________________________________________ City: _________________State:__________ Zip: _________ Social Security #: _______-______-_______ Email: ______ _____________________________________

Sex: � Male � Female Birthdate: __________________________ Age: __________ Marital Status: � Married � Single � Widowed � Separated � Divorced � Partnered for __________ years Occupation: ______________________________________ Employer/School: _________________________________ Employer/School Phone: ( ) _____________________

Spouse: Name: ____________________________________________ Birthdate: _________________________________________ Social Security: ________ - ________- __________ Spouse’s Employer: _________________________________ Phone: ____________________________________________ Whom May we Thank for Referring you to our office? ______________________________________________

Who is responsible for this account? ______________________________________________

Relationship to Patient: __________________________ Place of Employment: ___________________________ Insurance Company: _____________________________ Group # _______________________________________

Insurance Information: Subscriber’s Name: _____________________________ Birthdate: _____________________________________

SS# _______- _____ - _______

Insurance Company: ____________________________ Group # _____________________

Is patient covered by additional insurance? □Yes □No Please provide additional coverage information on back.

Assignment and Release:

I certify that I, and/or my dependent(s), have insurance coverage with the company(s) mentioned above and assign directly to Bella Smiles Dental, Inc. 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 authorize the use of my signature on all insurance submissions. The above-named dental office may use my health care information and my disclose such information to the above named Insurance Company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Date: _______________________20 _______________

______________________________________________ Signature of: Patient, Parent, Guardian or Personal Representative. __________________________________________________ Print Name of: Patient, Parent, Guardian or Personal Representative.

Please provide Insurance Card(s)

Home: _____________________ Work: __________________ Ext: ________ Cellular: ( ) ____________________ IN CASE OF EMERGENCY, CONTACT: (Specify someone who does not live in your household) Name: _____________________________________________ Relationship: ________________________________________

Medication: ________________________ _______mg Times______________ Diagnosis_______________________

Medication: ________________________ ______ mg Times_____________ _ Diagnosis_______________________

Medication: ________________________ _______ mg Times______________ Diagnosis_______________________

Comfortable Dentistry 4U