Welcome to PRECiDENT Let’s Get Started. Patient Intake Form Patient's Legal Name(Required) First Middle Last Preferred Name/Prefix Gender(Required) Marital Status Single Married Divorced Other Email(Required) Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Postal Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home #(Required)Cell #(Required)Work #Permission to Contact by(Required) Phone Call Text Message Email Work Phone ID # ID Type Driver’s License Military Alien Other Occupation Full-Time or Part-TimeFull-TimePart-TimeEmployer School Full-Time or Part-TimeFull-TimePart-TimeWhom may we thank for referring you? How did you hear about us? Internet Television Other Emergency Contact Name Relationship Home # Cell # Work # Emergency Contact Name Relationship Billing Address (if different than above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Home # Cell # Work # InsuranceTo ensure the submission and processing of insurance claims, please provide all requested information below.Primary Dental Insurance Company Phone # Name of Insured Employer Group/Plan ID Subscriber ID Claims Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Medical Insurance Company Phone # Name of Insured Employer Group/Plan ID Subscriber ID Claims Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code INSURANCEOur board-certified providers are not contracted with any insurance companies. We accept all insurance types and agree to courtesy file all insurance types (with the exception of medicare/medicaid); however, you understand that our providers are not held by contract to ‘allowable’ fees. You understand as the patient that while we will courtesy file your insurance, you are responsible for any balances not paid by your insurance. We will supply factual information necessary to process your claim(s); however, we will not become involved in disputes between you and your insurance company regarding claims, deductibles, covered charges, co-payments, discounts, secondary insurance, ‘usual and customary’ charges and other insurance issues.RELEASE OF INFORMATIONIn accordance with its Notice of Privacy Practices, PreciDent Center for Dental Medicine may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation 1) which is or may be liable to under contract to PreciDent Center for Dental Medicine, or reimbursement for services rendered, and 2) any health care provider for continued patient care and 3) family member as indicated by patient. A copy of this authorization may be used in place of the original. The following individuals have permission to receive information regarding the patient’s medical record and/or financial ledger until further notification is given.Name Relationship to patient Home #Cell #Work #Name Relationship to patient Home #Cell #Work #AUTHORIZATION, RELEASE & AGREEMENT TO PAY FOR SERVICES RENDEREDI authorize the doctor and other dentists or health-care professionals (interdisciplinary team members) to perform diagnostic procedures and treatment as may be necessary for proper dentofacial care. I authorize the taking of photos, radiographs, and other diagnostic records before, during and after treatment. I authorize PreciDent Center for Dental Medicine to release/obtain any information (via mail, fax or electronic) including the diagnosis and the records of any treatment or examination rendered to me/my child during the period of such dental/medical care to third party payors and other entities and/or health practitioners. I am aware that a HIPPA Notice of Privacy Practices is available to me as a patient and/or guardian.Signature of patient/guardian PhoneThis field is for validation purposes and should be left unchanged.
