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Atlantaneoralsurgery.com

Wm. Henry Wall, D.D.S.
Welcome. Thank you for selecting our office. We will strive to provide you with the best
possible dental care. To help us meet all of your dental needs, please complete this form to
the best of your knowledge. If you have any questions or need assistance, please ask – we
will be happy to help.
PATIENT INFORMATION (CONFIDENTIAL)
Patient’s Name __________________________________________________________________
Address:__________________________________ Apt #:_____________City_________________ State__________ Zip_______________ E-mail Address _________________________________ Home Phone (___)____________W ork Phone (___)___________Cell/Pgr(___)________________ Date of Birth_____/_____/_____ Social Security # _________________ DL #__________________ Patient’s Employer_________________________________________________________________ Name of Spouse_____________________________________ W ork Phone (___)______________ If Student, Name of School/College_________________________ Expected Grad. Date _________ Name of Responsible Party___________________________ Their W ork Phone (____)__________ Their Social Security #_______________________________ Their Cell Phone (____)___________ Is this person currently a patient in our office? Yes No Their Home Phone (____)___________ Person to Contact in Case of Emergency _______________________________________________ Their W ork Phone (____)___________________ Their Home Phone (____)___________________ About Today?
Purpose of Today’s visit? ____________________________________________________________ W hom may we thank for referring you? _________________________________________________ Do you have a current x-ray with you today? _____________________________________________ Are you experiencing any pain or discomfort in any of your teeth? ____________________________ Are you experiencing any pain or discomfort in your gums? _________________________________ Are you experiencing any pain or discomfort in your jaw joint? _______________________________ INSURANCE INFORMATION
Your insurance policy is a contract between you and your carrier. W e are happy to assist you in receiving allbenefits due to you. As a courtesy, we will file with your primary carrier only. Please remember that you areresponsible for your charges.
Primary Dental Insurance
Employee/Insured’s Name _________________________________Relationship to Patient________________ Employee/Insured’s Social Security Number___________________ Date of Birth________________________ Medicaid / Peachcare Number________________________________________________________________ Name of Employer_______________________________________ W ork Phone (____)___________________ Address of Employer_______________________________ City________________ State______ Zip________ Name of Insurance Company_________________________________ Group Number____________________ Address of Insurance Company_______________________ City________________ State______ Zip_______ Phone Number of Insurance Company________________________ Primary Medical Insurance
Employee/Insured’s Name _________________________________Relationship to Patient________________ Employee/Insured’s Social Security Number___________________ Date of Birth________________________ Medicaid / Peachcare Number________________________________________________________________ Name of Employer_______________________________________ W ork Phone (____)___________________ Address of Employer_______________________________ City________________ State______ Zip________ Name of Insurance Company_________________________________ Group Number____________________ Address of Insurance Company_______________________ City________________ State______ Zip_______ Phone Number of Insurance Company________________________ I certify that, to the best of my know ledge, the above information is true and accurate and I authorize Dr.
W all to release any information including the diagnosis and the records of any treatment rendered to me or my
child to any third party payors and/or health practitioners. I authorize and request my insurance carrier to pay
directly to Dr. W all insurance benefits otherwise payable to me. I understand that my dental insurance
carrier may pay less than the actual bill for services. I agree to be responsible for payment for all
services rendered on behalf of myself or my dependents. All payments or co-payments are due at the
time of service and may be made as follow s:

Please circle you choice: CASH
CREDIT CARD
X_________________________________________________ _______________________

Source: http://www.atlantaneoralsurgery.com/New_Patient_Info_-_2pg.pdf

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