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Bamidele J. Apapa, D.D.S., Inc.
30 West Rahn Road, Suite 12
Dayton, OH 45429-2238 937/298-5239. Fax: 937/298-5068
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Age
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PATIENT REGISTRATION (Please Print)
Date
Patient Name
OFemale Male Date of Birth
Address
Residence Telephone
City/State
Social Security Number
Cell Phone
Email
Employer
Referring Dentist
Nearest Relative or Friend
Business Tel
Position
Orthodontist
Physician
Relationship.
Res Tel
PRIMARY INSURANCE / PERSON RESPONSIBLE FOR ACCOUNT
Name
Relationship
Soc Security No
Address
City/State
Zip
Res Tel
Date of Birth
Employer
Bus Tel
Dental Insurance
Policy Number #
Medical Insurance
Policy Number #
SECONDARY INSURANCE / PERSON RESPONSIBLE FOR ACCOUNT
Name
Relationship
Address
City/State
Date of Birth
Employer
Dental Insurance.
Medical Insurance
Soc Security No
Zip
Res Tel
Bus Tel
Policy Number #
Policy Number #
FEES & PAYMENTS
We make every effort to keep down the cost of your oral surgical care. You can help, by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees and court costs.
This signature on file is my authorization for release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.
I certify that I have read and I understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.
Signature of patient:
(Parent or Guardian if minor)
Reviewed by:
Date:.