Confidential Patient Information

Patient Name

Current Address

Permanent Address (if different)

Contact Information

Personal Information

Person Responsible for Payment of Account

Spouse Information

How You Found Us

Dental Health Self-Assessment

Dental Insurance (Primary)

If you have dental insurance, please provide details; otherwise skip this section.

Dental Insurance (Secondary)

Medical Health

Allergies

Medical Conditions

Please check if you have or have had any of the following:

Acknowledgment & Signature

I authorize Drs. Strupp/Brumm to use the information above for my dental treatment. I acknowledge that a finance charge of 18% per year will be added to any account that is delinquent, and that Patient and Guarantor shall be jointly and severally liable for all reasonable costs and expenses (including, without limitation, reasonable attorneys' fees) incurred by the Dental Practice in collecting any past due amounts. Payment is due when services are rendered unless other arrangements have been made.