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Patient Information

  
 
Title______  First Name ___________________________________  Last Name_________________________________________
Birth Date____________________________  Social Security #__________________________________ Gender Male  Female
Address__________________________________________________________________ Apartment/Suite___________________
City___________________________________________________________ State___________________ Zip Code____________
Home Phone (_____) - ________________________  Work Phone (_____) - _________________________ Ext________________
Mobile Phone (_____) - ____________________ Fax (_____) __________________ Email_________________________________
Employer_________________________________ Phone (_____) - ___________________ Occupation______________________
Referred by__________________________________________ General Dentist_________________________________________

Person Responsible For Account (If other than patient)
Title______  First Name ___________________________  Last Name__________________________ Date of Birth ____________
Relationship to patient: Patient  Spouse  Child  Other, specify_______________ Social Security #_____________________
Address__________________________________________________________________ Apartment/Suite___________________
City___________________________________________________________ State___________________ Zip Code____________
Home Phone (_____) - ________________________  Work Phone (_____) - _________________________ Ext________________
Mobile Phone (_____) - ____________________ Fax (_____) __________________ Email_________________________________
Employer_________________________________ Phone (_____) - ___________________ Occupation______________________
 

Medical Insurance Information
Insurance Co._______________________________________ Group #_________________ Phone (_____) -__________________
Employer:_________________________________________________________________________________________________
Employee (If other than patient)
Title______  First Name ___________________________________  Last Name_________________________________________
Birth Date______________ Social Security #_______________________ Subscriber#_______________ Gender Male  Female
 

Dental Insurance Information
Insurance Co._______________________________________ Group #_________________ Phone (_____) -__________________
Employer:_________________________________________________________________________________________________
Employee (If other than patient)
Title______  First Name ___________________________________  Last Name_________________________________________
Birth Date______________ Social Security #_______________________ Subscriber#_______________ Gender Male  Female
 
Insurance claims are submitted for our patients as a courtesy. Our services are provided to the patient, not the insurance company. We will attempt to verify coverage whenever possible, however insurance verification is no guarantee of payment. Medicare and Tenncare may not cover the services provided to you (treatment of teeth and gums are not covered by Medicare). If you are covered under these plans and the services are not covered we will look to you for payment. I assign payment directly to Drs. McConnell, Slater, Napier, and Kennedy of the basic benefits as well as Major Benefits here is specified, and otherwise payable to me, but not exceed the regular charges for this period of treatment.
 

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__________________________

Signature of Patient or Guardian (If patient is a minor)

Date

   

___________________________________________________________

__________________________

Signature Authorized Representative

Date
 

Southeast Oral Surgery
Maryville Office: Phone 865-977-7110 Fax: 865-977-4132   /   Seymour Office: Phone 865-577-7800 Fax: 865-934-6989