The Exchange Dental Group

Harmohinder K. Oberoi D.M.D.

1 Bethany Rd. Bldg #1, Suite #18 Hazlet, NJ 07730

Phone: (732) 290-8090 Fax: (732) 203-0309

Date:

Patient Information

Name
DOB
Home #
Work #
Cell #
Best time to call
SS #
Family Status
Email
Address
Apt #
City
State
Zip
In case of an emergency who should be notified?
Phone #
Relationship to Patient
Who may we thank for referring you?
Name of person or office referring you to our practice:

Billing Party Information

Name of Head-of-Household:
Relationship to patient:
Phone #
Wk #
Cell #
Address
Street
City
State
Zip
SS #
DOB
Email Address

Insurance Information

Primary Insurance (Subscriber is the person responsible for insurance only)

Name of subscriber:
Is subscriber a patient?
Subscriber DOB:
Subscriber ID #
Group #
Group Name:
Subscriber Employer Name:
Address:
Patient's Relationship to Subscriber:
Other
Insurance Name and Claim Address:
Secondary Insurance
Name of Subscriber:
Subscriber DOB:
Subscriber Id #
Group #
Group Name:
Patient's Relationship to Subscriber:
Other
Insurance Name and Claim Address:

Insurance Information

All Smiles Dental Care

Health Information

Date:
Due Date
OTHER

Insurance Information

Are you taking any medications?
If yes, please list:
Have you been admitted to a hospital or needed emergency care during the past two years?
If yes, please explain
Are you under the Care of a physician?
If yes, please explain
Name of Physician:
Office #
Date of Last Dental Visit
Reason for This Visit
Have you ever had any complications following dental treatment?
If yes, please explain

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any other dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he/she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time of condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matter related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient

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Signature of Parent/Guardian

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Date
Relationship to patient