Contact Us | Lakewood Dental | Dentists in Batesville

Patient Information

Patient Name

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Address

Driver's License No.

Driver's License State

Employment Information

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Employer Phone

Employer Address

Permission to contact at work?
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Best time to contact

Insurance Information

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Insured's Date of Birth

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Dental Information

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Previous Dentist

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Additional Comments

Medical History

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Current Physician

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Consent & Acknowledgements

I understand and agree to the financial policy.
I understand and agree to the HIPAA disclosure.
I have reviewed and confirmed my medical history.
I grant permission for secure online storage of my information.

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Lakewood Dental may use my health care information and may disclose such information to my Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

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