Name: EPIC: Exceptional Periodontal and Implant Concepts
Address: 3475 Plymouth Blvd. Suite 200, Plymouth, Minnesota, 55447, US
Price range: $$$

Patient Information

Date
MM
DD
YYYY
Patient's Legal Name
First Middle Last
How do you prefer to be addressed? Nickname?
First Last
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone
Home Phone
Work Phone
Martial Status
Sex
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- Male
Email
Date of Birth
MM
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YYYY
Social Security # (if needed to process your insurance)
Employer's Name
Referred by
Is this your general dentist?
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- No
If no, list your general dentist
Pharmacy Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Emergency Contact
First Last
Phone
Insurance Information
Primary Dental Insurance Name
Group #
Patient ID
Phone
Insurance Claims Address
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Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's SS# (if needed to process your insurance)
Policy Holder's Address
Street Address Address Line 2 City State ZIP Code
Policy Holder's Employer
Relationship to patient
Secondary Dental Insurance Name (if applicable)
Group #
Patient ID
Phone
Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's Date of Birth
Policy Holder's SS#
Policy Holder's Address
Street Address Address Line 2 City State ZIP Code
Policy Holder's Employer Address
Street Address Address Line 2 City State ZIP Code
Relationship to patient
I understand that the information on the Registration, Medical History, and Dental History forms are necessary to provide dental care in a safe and efficient manner. I have answered the questions to the best of my knowledge. Should further information be needed, the staff of Jeanne L. Barss DDS, MS, PA has permission to ask the respective Health/Dental care provider to release such information. I will notify this office of any changes in my health or medications. If payment for services rendered is not made in a timely manner, your account may be turned over to an outside collection agency and you will be responsible for collection fees. A $25 fee will be charged for insufficient funds on returned checks. A late (less than 48 hours) cancellation fee of 10% of your surgery amount may apply. The late (less than 48 hours) fee for cancelled maintenance appointments is $50. I understand that I am financially responsible for all charges regardless of insurance coverage.