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Alexandra Dodds DDS
Phone
: (616) 245-3205
Fax
: (616) 245-7270
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New Patients
General Information
Preferred
Y
N
Preferred Pronouns
He
She
They/Them
Other
Patient is
Policy Holder
Responsible Party
Whom may we thank for referring you to our office?
Patient Information
Address/Phone
Sex
M
F
Marital Status
M
S
D
W
Under 18
Birth date
Social Sec #
Email Address
I would like to receive email correspondence
Y
N
Employment Status
Full Time
Part Time
Retired
N/A
Student Status
N/A
Full Time
Part Time
Emergency Contact
Responsible Party (if someone different than the patient)
Address/Phone
Birth date
Social Sec #
Drivers Lic #
Responsible party is also the policy holder for
Patient
Primary Insurance
Secondary Insurance
Primary Insurance Information
Name of Insured
Self
Spouse
Child
Other
Insured Social Sec #
Birth date
Employer
Insurance Company
Group Number
Policy ID #
Secondary Insurance Information
Name of Insured
Self
Spouse
Child
Other
Insured Social Sec #
Birth date
Employer
Insurance Company
Group Number
Policy ID #
ASSIGNMENT & RELEASE
I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balances due and authorize the dentist to release any information for this claim. I authorized that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office I am obligated to pay aid office in accordance with its credit terms and policy. I consent to the making of videotapes, photographs, and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
Signature of Patient/Legal Guardian:
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