Killeen Dental Health Center, pa
CRAIG W. MOLYNEAUX, D.D.S.                                                                                         TODD B. PERRIN, D.D.S.

Patient Information

Name of Patient        SS# 
Address                  Apt #     City    State    Zip 
Home Phone              Work Phone         Cell Phone/Other 
Date of Birth            Age      Sex     Race    Marital Status
E-mail Address      Employer    Position
Parent or Responsible Party (if patient is under age 18)
       
Mother/Guardian's Name  Father/Guardian's Name 
Date of Birth        Marital Status Date of Birth        Marital Status
Social Security No. Social Security No.
Address    Apt #  Address    Apt # 
City   State    Zip City   State    Zip
Home No .  Cell No. Home No .  Cell No.
 Employer     Work No. Employer     Work No.
Email Address Email Address
Will the above party be responsible for any balance on the
account?    		 Will the above party be responsible for any balance on the
account? 
Emergency Information
 
Emergency Contact Phone Number  
Relationship to Patient?  Has the patient received treatment here previously?  
Has any member of your family been seen here before? If yes, patient's name  

 If the Patient is Covered by Any Dental Insurance, Please Fill Out the Following:

Insurance Name Insurance Phone No.
Employer  Group No.
Subscriber's Name Subscriber's Date of Birth
Subscriber's SSN or ID # Relationship to Patient
Rank (If Military) Military Branch
Sponsor's Unit (If Military) Unit Phone Number
If the Patient is Covered by a Second Insurance, Please Fill Out the Following:
Insurance Name Insurance Phone No.
Employer Group No.
Subscriber's Name Subscriber's Date of Birth
Subscriber's SSN or ID # Relationship to Patient
Rank (If Military) Military Branch
Sponsor's Unit (If Military) Unit Phone Number
Consent for Services

I understand that forms for insurance claims will be submitted as long as I provide all the information necessary to complete filing. I authorize release of any information concerning the health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I hereby authorize payment of insurance benefits directly to the dentist. Staff will calculate ESTIMATED deductible and co-pay. Payment of this amount is due the day services are rendered. I understand that I am responsible for all costs of dental treatment within 30 days.

 

Patient or Legal Guardian's Signature:_________________________________________________   Date: ________________________