Donald L. Taylor, Jr., D.D.S.

PATIENT INFORMATION FORM

PATIENT________________________________Age_______Home Phone _______________

Address______________________________City____________State_____Zip______________

Date of Birth_____________Social Security Number___________________________________

If student, grade_______School/College _____________________________________________

RESPONSIBLE PARTY___________________________Home Phone___________________

Address______________________________City____________State______Zip_____________

Employer____________________Occupation _____________Work Phone__________Ext.____

Relation_______________Social Security Number ________________Date of Birth__________

SPOUSE_________________________Social Security Number__________________________

Address________________________________City______________State______Zip_________

Spouse=s Employer________________Work Phone_____________Date of Birth_____________

Whom may we thank for referring you?______________________________________________

Whom may we contact in the event of an emergency?___________________________________

Relationship__________________________Home Phone ______________________________

Previous Dentist_____________________________________Last Visit____________________

Insurance Company (1) ___________________________ Subscriber ______________________

Group Number___________________________ I.D. Number ___________________________

Insurance Company (2) __________________________Subscriber________________________

Group Number___________________________I. D. Number____________________________

I WILL BE PAYING TODAY BY: Cash_____Check_____Credit Card_____(Please check one)

I agree that I am ultimately responsible for any account balance for services rendered. I certify that the above information is true and correct to the best of my knowledge. In the event that my account has to be referred for collection, I agree that I am responsible for any and all costs of collection fees, which is 33.33% of the balance, or legal fees, which may be up to 50% of the amount due. I acknowledge that I have read and understand the terms of this agreement.

Responsible Party=s Signature_____________________________Date_____________________

I hereby give authorization that all third-party payments of my/our dental benefits (Insurance, etc.) otherwise payable to me or my family be made directly to Donald L. Taylor, Jr. D.D.S.

Responsible Party=s Signature_____________________________Date_____________________