www.ParkCitiesDentalCare.com
J. Eric Hibbs, DDS, FAGD

5600 W. Lovers Lane @ Tollway #216
Dallas, TX 75209-4369    E-mail: dentist@birch.net
Phone: 214.351.2311  Facsimile: 214-351-23891  Toll-Free: 877-DR-HIBBS

Please fill out this form and click "Submit," or print it, and bring it with you.  You may also save or print and  e-mail, fax , or mail form prior to appointment! Click for  pdf format

Patient Name:   Preferred Name:
                                  Last
,   First   Middle                   
Male  Female          Married  Single  Child  Other:

Social Security #:
Driver License #: (St): Birth Date:
Phone (Hm): (Wk):
Ext:     Cell:
Address:
 
                      
Street    Suite/Apt#    City    State    Zip           
Employer Name: Occupation:
Address:
    E-Mail Address:  
                      
Street                    Suite/Apt#    City    State    Zip                                                  
Please secure your account: Credit Card Type: #: Exp:
                                                 I do not wish to secure my account; I will pay all fees at time of service.

Reason for this visit: Date of Last Dental Visit:
Are you interested in: Lumineers   Implants   Invisalign  Changing Appearance of Your Smile

How would you like to set up your initial appointment?Call me   I'll call you   Send me an e-mail

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:
Now under the care of a physician? No Yes: Name: Ph:
Any health problems that need further clarification? No  Yes:
Emergency Contact: Name of nearest relative not living with you?
Complete address: Ph:
                                Street    Suite/Apt#    City    State    Zip 

Referral Information
How did you hear about our practice? Referred by:  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   Middle
Insured's Birth Date: ID #: Group #:
Insured's Address:

                                       Street    Suite/Apt#    City    State    Zip           
Insured's Employer Name:
Address:

                    Street    Suite/Apt#    City    State    Zip                             
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   Middle
Insured's Birth Date: ID #: Group #:
Insured's Address:

                                       Street    Suite/Apt#    City    State    Zip           
Insured's Employer Name:
Address:

                     Street    Suite/Apt#    City    State    Zip                            
Patient's relationship to insured: Self  Spouse  Child  Other:
Insurance Plan Name:
Address: Phone:
                Street    Suite/Apt#    City    State    Zip 

Responsible Party (if other than patient) Information

Name:   Relationship to minor patient: 
             Last,   First   Middle                                              Male  Female                                              
Social Security #: Birth Date:
Phone (Hm): (Wk): Ext: Cell:
Address:

               Street    Suite/Apt#    City    State    Zip                 

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 1% 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
Additional Comments:  

              
 Copyright 2011 J. Eric Hibbs, DDS