Village Family Dental
 
New Patient
Forms - 1 of 4
New Patient Forms
HIPPA
Schedule an Appt.
Financial Information
FAQ's
VFD Links
New Patient PDF
 
We appreciate your loyalty
and referrals to friends, family
and acquantances!
Request Appointment
 
 
Today's Date:
Last Name:
First Name
Middle Initial:
Birth Date:
Sex:
Marital Status:




SS#:
If Child-Parent's Name:
   
Home Phone:
Cell Phone:
Work Phone:
Contact at Work?
Email Address:
Best Contact:  
   
Street Address:
City:
State:
Zip Code:
Patient/Parent Employer:
Business Street Address:
Business City:
Business State:
Business Zip Code:
   
Spouse Name:
Spouse SS#:
Spouse Employer:
   
Responsible Party:
Drivers License #:
   
Do you have insurance that may cover a portion of the charges?
   
Family members in
this practice:
Subscriber's Birth Date:
Subscriber's SS#:
Subscriber's Employer:
Emergency Contact:
Who referred you?
Why did you change Dentists?

RELEASE
I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

I authorize release of any information concerning my (or my child’s) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor.

I attest to the accuracy of the information on this page.
   
Accpet These Terms:
   
 
 
Village Family Dental
Patient Quote:

I couldn’t have done it without sedation dentistry. I was embarrassed to smile, couldn’t chew my food properly and was very afraid. Now I am smiling, eating what I want and have my confidence back again.

 
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