Yang Family Dentistry Patient Med History - Formstack

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	Patient Information
	Name*	Date Of Birth* Month Day Year
	Address City State Zip Code
	Home Phone	Marital Status
	Work Phone	Cel Phone
	Email*	Social Securty Number* Your info is secure- we use SSL!


	Person to contact in case of emergency
	Name*	Phone*


	Whom may we thank for referring you?
	Name


	If patient is a student, please list name of school or college
	School


	Spouses name or parents name if patient is a minor
	Name


	Responsible Party Information (If different from above patient information)
	Name* Name of person responsible for this account	Date Of Birth* Month Day Year
	Address City State Zip Code
	Home Phone	Cell Phone
	Work Phone	Email
	Social Securty Number* Your info is secure- we use SSL!	Relationship to Patient


	Dental Insurance Information
	NAME OF INSURED	Date Of Birth* Month Day Year
	RELATIONSHIP TO PATIENT	SOCIAL SECURITY NUMBER Your info is secure- we use SSL!
	EMPLOYER	WORK PHONE NUMBER
	ADDRESS OF INSURED (if different from responsible party) City State Zip Code
	DOES PATIENT HAVE ADDITIONAL DENTAL INSURANCE COVERAGE? Yes No I don't know
	Dental Insurance IN ORDER TO PROPERLY FILE YOUR INSURANCE, WE MUST HAVE A COPY OF YOUR INSURANCE CARD AND THE ABOVE INFORMATION MUST BE COMPELETLY FILLED OUT. WE ARE NOT RESPONSIBLE FOR TRACKING DOWN YOUR INSURANCE INFORMATION.


	Financial Policy Thank you for choosing Yang Family Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
	Payment Options: You can choose from: Cash, Check, Visa or MasterCard NO INTEREST Payment Plans from CareCredit: Allow you to pay over time with NO INTEREST Convenient, low monthly payment plans also available No annual fees or pre-payment penalties Please note: Yang Family Dentistry requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received. We accept payments in thirds for treatments over $500. For plans requiring more than 3 appointments, alternative payment arrangements may be provided. For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. A fee is charged for patients who miss or cancel more than 1 time in a calendar year without 24-hour notice. Yang Family Dentistry charges $25 for returned checks. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Parent, Patient or Guardian Signature Date Patient Name (Please Print)