New Patient Financial/Insurance Form

East Madison

Thank you for choosing our office for your child’s/children’s dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party.

If the information in this form is the same for each child, please complete only one form. If information varies for children in your family, please complete additional financial/insurance forms as needed.

Child's Date of Birth:

2nd Child's Date of Birth:

3rd Child's Date of Birth:

Additional Children and/or Comments:

Relationship to Child:

Marital Status:

Single Married Divorced Widowed

Social Security Number:

Driver's License Number:

Relationship to Child

Marital Status:

Single Married Divorced Widowed

Social Security Number:

Driver's License Number:

Relationship to Child

Who is responsible for making payments:

Emergency Contact Name:

Emergency Contact Phone:

Alternate Emergency Contact

Alternate Emergency Contact Phone:

Insurance Company Name:

Insurance Company Address:

Insurance Company Phone:

Group # (Plan, Local or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate:

Policy Owner's Employer:

Do you have dual (secondary) insurance?

Yes (continue to fill out this section) No (go to step 10)

Insurance Company Name:

Insurance Company Address:

Insurance Company Phone:

Group # (Plan, Local or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate:

Policy Owner's Employer:

How did you find us?

If you were referred, who referred you?

Hippa Consent

I have been informed by your office of your Notice of Privacy Practices with a complete description of the uses and disclosures of my health information. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action on this consent.

Financial Policy

I have been informed by your office of your Notice of Privacy Practices with a complete description of the uPayment is due when services are rendered. We accept cash, personal checks and all major credit cards. We realize that some procedures are more extensive than others and we will be more than willing to work out alternative financial arrangements prior to treatment. I understand and agree that, (regardless of my insurance status or marital status), I am ultimately responsible for the balance on this account for any professional services rendered. I have read the above information and understand my obligations.ses and disclosures of my health information. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action on this consent.

By printing my name I am consenting to electronically signing this form.

Relationship to Patient

View Our Open Job Listings

Fitchburg:
(608) 288-1543

East Madison:
(608) 825-7500

West Madison:
(608) 833-6545

Sun Prairie:
(608) 453-5600

New Patient Financial/Insurance Form

East Madison

(608) 288-1543

(608) 825-7500

(608) 833-6545

(608) 453-5600