Dental History

New Patient Information
Last Name:*
Last
First:*
First
Preferred or Nickname:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone:
Work Phone:
Cell phone:
SS#
Date of Birth:
Sex:*
- M
- F
Marital St:
Email Address:
How do you prefer to be contacted:
Who may we thank for referring you?
Emerg. Contact:
Patient Employer/School:
PRIMARY INSURANCE COVERAGE
(Please provide your card for our records):
Policy holders Name:
First
SS#:
DOB:
Member ID#:
Group ID#
Insurance Company:
Employer Name:
SECONDARY INSURANCE COVERAGE:
(if applicable)
Policy holders Name:
First
SS#
DOB:
Member ID#:
Group ID#:
Insurance Company:
Employer Name:
Assignment and Release: I certify that I, and/or my dependent(s), have insurance coverage with the above listed insurance company(ies) and assign directly to Dr. Karen Glerum 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 all my signature on all insurance submissions. The above named dentist may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services determining insurance benefits of the benefits payable for related services.
Patient Signature:
Date

Practice Policies
Our Primary goal is for each patient to establish or maintain a “Healthy Mouth” through our excellent and efficient care. In an effort to keep our fees reasonable ant o continue to provide quality care, we have established the following policies:
- Payment is due at the time that the service is rendered. Although we are happy to submit your insurance on your behalf as a courtesy, your insurance policy is not a guarantee of coverage. In addition, certain procedures may not be covered at all. There could also be deductibles and annual maximums that may apply.
- All necessary dental treatment will be recommended. In this case, a treatment plan will be presented to you, and it will include several different payment options. This will allow you to proceed with your needed treatment while still maintaining your lifestyle. All treatment must be paid in full upon completion of the treatment and any appointment exceeding a value of $500 will require a deposit of 30%. In some cases, pre-payment may be required.
- Outstanding balances are not permitted. Before we can schedule any new services or appointments, payment for prior services must be collected. Any failure to pay in a timely fashion, may subject your account to finance charges.
- We know that you have a busy schedule and we respect your time! We request that you respect ours as well. We strive to see all of our patients on time. If you are late for your appointment, you many need to reschedule
- We do enforce a 48hr cancellation policy. Your appointment time has been set aside especially for you. If you are unable to keep your appointment we ask that you provide 48 hours notice in order to avoid the cancellation fee of $100.
By Signing Below, you acknowledge and agree to adhere to these policies.
Patient signature
Date

Smiles By Glerum

Step 1 of 4

New Patient Information

PRIMARY INSURANCE COVERAGE

SECONDARY INSURANCE COVERAGE:

Practice Policies

By Signing Below, you acknowledge and agree to adhere to these policies.

Medical history

If female:

Do you have - or have you ever had - any of the following conditions and/or treatments?

Pharmacy Information: