FirstName : LastName : Date of Birth : Sex: M / F Marital Status : Social Security Number: Home Address (Street): (City ): (State): (Zip) : Home Phone # Cell Phone# Home E-Mail Name of Employer Occupation (If full-time Student) Name of School/Grade Business Address (Street) (City) (State) (Zip Code) Business Phone Number

The Responsible party holds the primary insurance coverage for you.
Name of Responsible Party: DOB Spouse/Parent Social Security

Name of your Primary Dental Carrier Insurance Id Subscriber Secondary Insurance? yes / no #Spouse's Name DOB Children's Names & Ages

In case of Emergency, call : General health (please check) : EXCELLENT GOOD FAIR POOR (Name, address, and Phone number of close relative NOT living at your home address.) :

Name of physician What are your hobbies? Special Interests? How did you hear of Dr.Kenwood?

I authorize the release of information, related to my or my family's dental care, to my benefits carrier and assign my/our benefits to your office. I authorize you to sign my signature or write "signature on file" for me in the above matters and forbid my carrier from selectively validating any of my and/or my family members' authorizations to this office. If any one of my "authorizations/signatures" are deemed invalid by my carrier, I revoke all of my authorizations and request that the claim be returned unprocessed. Regardless of my dental benefit(s) plan, I recognize that I am ultimately responsible for dental expenses incurred by myself and/or my family in your office. I have authorized the dentist and his/her staff to diagnose, administer medications and dental treatment necessary for proper dental care. The information and medical history provided by me on attached page is correct to the best of my knowledge and I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions I have made in completing this form. I have reviewed and accept your HIPPA privacy policies. Unless I notify you in writing, I allow you to use any photographic, video or radiographic images for educational purposes. I acknowledge limitations to security for email conversations and accept that risk when providing email addresses. I acknowledge that payment in full is due pior to or at the time services are rendered unless I have assigned my dental benefits to your office and have preauthorized your office to place any unpaid balances on my credit card of file at your office once that claim is processed. Acknowledgement of the amount due will be attempted. Additional billing and collection fees may be applied for unpaid balances. Futhermore, I agree to be charged a time proportionate fee ($45 minimum) for any appointment that I cancel without 24 hour prior notice to your office.

Signature of Responsible Party Date Print Name Relationship to patientIf patient is LESS THAN 18 YEARS OLD, parent or legal guardian MUST sign above.