The Bite Dental - Patient Information
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Patient's Name
Age *
Date of Birth *
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Address *
City *
State *
Zip *
Home Phone *
Work Phone *
Mobile *
E-mail *
Preferred Contact Method *
Best Time to Contact *
Marital Status *
Spouse' Name
Spouse's Phone
Employer *
Employer's Address
Emergency Contact *
Relation *
Emergency Phone *
Do you have dental insurance?
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Insurance Carrier's Name
Group #
Subscriber's Name
Phone
Subscriber's SS or Mem ID#
Subscriber's Date of Birth
MM
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DD
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YYYY
Employer/Co. Name
Phone
Employee Co. Address
Insurance Carrier Address
How did you hear about us?
Would you like to receive appointment reminder via text message? *
Would you like to become friends with The Bite Dental on Facebook to receive special offers? *
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 the The Bite Dental at the time of my visit. Failure to provide our office with all the information necessary to file your 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 (30) 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 addeds to my account for any overdue balance that is my responsibility.
Name *
Date *
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Terms and Conditions
By submitting this form you are agreeing to the terms and conditions of the Bite Dental Inc, which can be found here:
https://thebitdental.com/home
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