11420 W Broad St, Glen Allen, VA 23060 | bradleyranderson@live.com
 
CALL US TODAY! 804-360-3500
 
 
 
 
 
 
 

Dentist New Patient Form in Glen Allen, Virginia


 

New Patient Form

 
 
* Birthdate
 
 
 
 
* Gender
 
 
 
 
 
 
 
 
 
DENTAL INSURANCE
 
 
 
 
 
 
 
 
 
 
* Policy Holder Date of Birth
 
 
PERSON RESPONSIBLE FOR ACCOUNT
 
 
* Birthdate
 
 
 
 
 
 
 
MEDICAL AND DENTAL HISTORY
HAVE YOU EVER HAD:
 
Hepatitis or Liver Disease
 
Joint Replacement
 
 
Rheumatic Fever
 
Diabetes
 
 
High/Low Blood Pressure
 
Heart Trouble
 
 
Heart Murmur
 
A.I.D.S.
 
ARE YOU:
 
If female are you now pregnant
 
Aware of grinding or clenching your teeth day or night
 
 
Interested in whitening your teeth
 
Presently under the care of a physician
 
ANY ALLERGIC REACTION TO:
 
Latex
 
Anesthetics
 
If Yes, please list.
 
 
 
 
Codeine
 
Antibiotics
 
If Yes, please list.
 
 
 
 
Sulfa Drugs
 
Aspirin
 
 
 
If Yes, please list.
 
 
I hereby authorize Dr Bradley R Anderson to furnish information to insurance carriers concerning my treatment and I hereby assign to the dentist all payment for dental services rendered to myself or my dependents. I understand I am responsible for any amount not covered by the insurance.
In order to provide the best care at the lowest cost, payment is due at the time of service including insurance co-pays and deductibles. Unpaid balances will be subject to a service charge of 1.5% per month and annual rate of 18%. I agree to pay all collection, attorney and / or interest fees acquired if necessary to collect on this amount.