Welcome to Glen Valley Dentistry, we appreciate your time in filling out the information below. Please bring printed information with you for your appointment. You can also e mail this page to appointments@gvdentistry.com. You will need to save this page as a .doc then fill in the appropriate fields on your computer then send as an attachment. We will obtain your signature at your appointment.

Everything on this form can be selected before printing, except the signatures at the bottom. ~ 3 sheets will print

PATIENT INFORMATION

Name:                                     Birthdate:
Address:
Email: Home Phone: Cell Phone:
Select appropriate box: Single Married Divorced Separated
Spouse or Parent/Guardian Name:
Patient or Parent/Guardian Employer's Name:
Business Address:
Business Phone:
Who should we contact in case of emergency?
Phone # where to reach them?
Whom may we thank for referring you?

PERSON RESPONSIBLE FOR THIS ACCOUNT

Name: Realtionship to patient:
Birthdate: Email:
Address:
Home Phone: Cell # Work #
Employer:
Is the responsible person for this account a patient of Glen Valley Dentistry Yes No

INSURANCE INFORMATION

Name of Insured: Relationship to patient:
Birthdate: Work #
Insurance Company Name: Insurance ID #

SECONDARY INSURANCE INFORMATION (if applicable)

Name of Insured: Relationship to patient:
Birthdate: Work #
Insurance Company Name: Insurance ID #

Name                     
Are you under the care of a physician? Yes No
Have you ever been hospitalized or had a major operation? Yes No
Are you taking any medications, pills or drugs? Yes No
If yes please list below :

Do you take or have you taken, Phen Fen or Redux? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No              Do you use controlled substances? Yes No    
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetic
Other:

Do you have or have had any of the following?

Have you ever had any serious illness not listed above? Yes No

       
Patient Signature (after printed)__________________________________Date Signed_______________

PRINT NOW AND SIGN BOTH SHEETS PLEASE (unless you are e mailing then you will have opportunity to sign when you come in)

Glen Valley Dentistry
9041 North Rodgers Drive, Caledonia MI 49316
616-891-8931

We recognize the need for a definite understanding between patient and dentist regarding financial arrangements for dental care. Responding to this need we have established the following financial policy. Please take a moment to read through the policy and sign.

To our patients with insurance:

Please remember that your insurance coverage is a contract between you and your insurance company and is not a substitute for payment. We are happy to work with you and your insurance company but you are ultimately responsible for your account. We will gladly bill your insurance company, but your portion is due the day of treatment. Payment is required within 15 days of notification.

To our patients without insurance:

We request that all charges be paid at the time of each visit.

Statement Fee
A $3.00 billing fee will be added to your balance if statements are sent out. If the account becomes past due and turned over to collections, you are responsible for the cost of such collection procedures and you and your family will be dismissed from the practice.

Missed Appointment Fee:

If you cannot keep your appointment, please provide at least 24 hours advance notice or you may be charged a cancellation fee.

I/ We understand and agree to the above policy .


__________________________                    _________________      
Signature of Patient or Legal Guardian                Date

__________________________                    _________________
Signature of Patient or Legal Guardian                Date




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