www.ParkCitiesDental.com
J. Eric Hibbs, DDS, FAGD
5600 W. Lovers Lane @ Tollway #216
Dallas, TX 75209-4318    214.351.2311

Please print this page, fill it out, and bring it with you.  Or, for faster service, fax or mail form prior to your appointment!
Patient Name: _______________________________________________________________________________ 
                                            Last                                    First                                           MI                               Preferred Name
Male  Female                                           Married  Single  Child  Other: __________________

Social Security #: _________________ Driver License #: _________________(State)___ Birth Date: ________

Phone (Home): ____________ (Work): ____________ Ext: ____ Cell: ______________ Pager: ______________

Address:____________________________________________________________________________________                                         
                                  Street                                   Apt #                  City                                      State                   Zip Code 
Employer Name: ___________________________________ Occupation: _______________________________

Address:____________________________________________________________________________________                                           
                                  Street                                Suite#                 City                   State             Zip Code           Your E-Mail Address 

· How will you secure your account? Credit Card: _______ #: ______________________ Expires: ______
                                                      I will pay at time of service during each visit.
· Reason for this visit: _________________________________ Date of Last Dental Visit: ________________

· Are you interested in: Fresher Breath   Whiter Teeth   Changing Appearance of Your Smile

Have you ever had or do you now have any of the following? Please check those that apply:
Codeine Allergy  Penicillin Allergy  Sulfa Allergy  AIDS  Allergies _________________  Anemia Arthritis  Artificial Joints  Asthma  Blood Disease  Cancer  Diabetes  Dizziness  Epilepsy  Excessive Bleeding  Fainting  Glaucoma  Growths  Hay Fever  Head Injuries Heart Disease  Heart Murmur  Hepatitis Type:__  High Blood Pressure  Jaundice  Kidney Disease Liver Disease  Mental Disorders  Nervous Disorders  Pacemaker  Pregnancy  Pregnant: Due date:___________  Radiation Treatment  Respiratory Problems  Rheumatic Fever  Rheumatism Sinus Problems  Stomach Problems  Stroke  Tuberculosis  Tumors  Ulcers  Venereal Disease Osteoporosis
Other, please describe: _______________________________________________________________

· What medications are you taking?________________________________ Why?_______________________

· Have you ever had any complications during or following dental treatment? No  Yes: _______________

· Are you now under the care of a physician? No  Yes: Name: _________________ Ph: ______________

· Do you have any health problems that need further clarification? No  Yes: ________________________

· Emergency Contact: Name of nearest relative not living with you? __________________________________
Complete address: __________________________________________________ Phone: __________________

Referral Information
How did you hear about our practice? ________________________________  Office Sign  Post Card Dallas Yellow Pages  Park Cities Yellow Pages  Internet Web Site  Other:__________________

Dental Insurance Information

Primary:
Name of Insured: ______________________________________________ Is insured a patient? Yes  No
                                       Last                         First                        MI
Insured's Birth Date: _________________ ID #: _____________________ Group #: ___________________

Insured's Address: ________________________________________________________________________
                                        Street                                                    City                               State                        Zip Code
Insured's Employer Name:__________________________________________________________________

Address:________________________________________________________________________________
                                        Street                                                    City                               State                         Zip Code
Patient's relationship to insured: Self Spouse Child Other: ______________________________

Insurance Plan Name and Address: _________________________________________________________

Phone #: _________________        _________________________________________________________

Secondary (Additional Insurance):
Name of Insured: ______________________________________________ Is insured a patient? Yes  No
                                     Last                                    First                       MI
Insured's Birth Date: _________________ ID #: _____________________ Group #: ___________________

Insured's Address: ________________________________________________________________________
                                       Street                                                       City                                State                         Zip Code
Insured's Employer Name: __________________________________________________________________

Address: ________________________________________________________________________________
                                        Street                                                      City                                State                         Zip Code
Patient's relationship to insured: Self  Spouse  Child  Other: _____________________________

Insurance Plan Name: _____________________________________________________________________

Address: _____________________________________________________________ Phone: ____________

 

Responsible Party (if other than patient) Information

Name: _________________________________________________________________________________
                          Male  Female                                                    Relationship to minor patient
Social Security #: ________________________________ Birth Date: ______________________________

Phone (Home): ____________ (Work): ____________ Ext:____ Cell: ____________ Pager: ___________

Address:________________________________________________________________________________
                         Street                     Apartment #                    City                              State                     Zip Code

Consent for Services

As a condition of your treatment by this office, the patient is responsible for ensuring payment of the full fee charged for all treatment performed.  All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed.  Patients who require special financial arrangements must notify us in advance. 

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.  Estimates of patient co-pay amounts are not a guarantee of the final amount due, which will be determined and billed after all insurance payments have been received.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. 

I understand that dental care fee estimates can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder, as allowed by state law.

I have read the above conditions of treatment and agree to their content.  I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.  I hereby authorize any past due amounts to be charged to my securing card account.

To the best of my knowledge, all of the preceding answers and information provided are true and correct. 
If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

________________________________________  Date: _______________  Relationship to Patient: ________________________
Signature of patient, parent or guardian