Confidential Information Questionnaire

8975 E. Golf Links Rd.
Tucson, AZ 85730
(520)886-6054
www.dentalcaretucson.com

Confidential Information Questionnaire

Confidential Information Questionnaire

Confidential Information Questionnaire

"*" indicates required fields

Patient Information

Patient Name:*
Address
MM slash DD slash YYYY
How would you like to be reminded of your appointments?
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Billing Information (if different from above)

A firm financial arrangement is required before treatment. Patient’s estimated portions are due the day services are rendered.
We accept the following payment options. Please indicate your choice below:
A firm financial arrangement is required before treatment. Patient’s estimated portions are due the day services are rendered. We accept the following payment options. Please indicate your choice below:*
Dental Care on Golf Links will pursue any and all collection efforts including referring the account to a collection agency and/or attorney and reporting to the credit bureau. The patient account will be assessed all additional collection charges associated with the collection of debt including but not limited to collection fees, reasonable attorney’s fees, court costs, and all other charges allowed by law.

Dental Insurance

Do you have dental insurance?
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If yes, please list primary insurance below:
MM slash DD slash YYYY
Do you have secondary dental insurance?
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If yes, please list secondary insurance below:
MM slash DD slash YYYY
I hereby authorize my insurance benefits to be paid directly to Dental Care on Golf Links, PLC. I also authorize the doctor to release any information required to process insurance claims. I will pay the estimated portions for treatment the day of service and any balance after insurance has paid.
MM slash DD slash YYYY
MM slash DD slash YYYY