Welcome

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Bruce M. Rogers, D.D.S., 19621 Yorba Linda Blvd., Yorba Linda, CA 92886, (714) 970-6331

About You

Today's Date:

E-mail Address:

Name:

Last

First

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I prefer to be called:

Male Female

Birthdate:

Age:

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Home Address:

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Where & when are best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

Employer:

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Responsible Party

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Spouse Information

His / Her Name:

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Insurance Information

Primary Insurance Dental Coverage?

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Insurance Co. Name:

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Insured's Name:

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Secondary Insurance Dental Coverage?

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Insurance Co. Name:

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Insured's Name:

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Insured's Employer:

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Dental History

Medical History

History Review

Dentist Signature:

Date:

Authorization & Release

I certify that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform the office of any changes in my medical status. I understand that providing incorrect or incomplete information can be dangerous to my health. I authorize Dr. Rogers to perform all recommended treatment mutually agreed upon. I authorize the release of any information, including the diagnosis and the records of any treatment rendered to me or my child, to third party payers and/or health practitioners. I authorize and request my insurance company to pay, directly to the dentist, insurance benefits otherwise payable to me. I understand that my dental insurance may not cover all the costs of treatment. I agree to be responsible for payment of all services rendered an my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event any payments ore not received by agreed upon dates, I understand that a 1 1/2% late charge (18% APR) may be added to my account.

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Signature of Patient or Parent/Guardian if a Minor

Date

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Relationship to Patient