When was your last
complete physical examination? _____________________

• Physician's Name __________________________
  

• Physician's Telephone ______________________

Allergies To:

• Penicillin     Codeine     Novocaine
  

• Others: ____________________

In Case of Emergency, Who Should Be Notified?

• Name ___________________________________   Telephone ____________________

• Name ___________________________________   Telephone ____________________

I authorize the dentist treating me to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care.

Signature __________________________________   Date _________________________

FINANCIAL POLICY, PLEASE READ AND SIGN

I understand that I am financially responsible to Doctor Gatens for all charges incurred by me and/or my dependents.   I agree that in the event my account is past due for 60 days from the date of services, and is turned over to an attorney for collection, I will be liable for collection fees in the amount of 1/3 of the principal balance (minimum $50.00) plus all court costs.   I will pay interest on accounts past due 60 days or more at the rate of 1.5% per month (minimum $2.00).   There will be a $25.00 charge for any returned checks.

Signature _____________________________________   Date _______________________

IF YOU HAVE INSURANCE THAT YOU WISH US TO FILE, THEN PLEASE READ AND SIGN

I hereby assign all medical, dental and/or surgical benefits to which I am entitled for this service to Doctor Gatens.  This assignment will remain in effect until revoked by me in writing.  A photocopy of this assignment is to be considered as valid as an original.  I understand that I am financially responsible for any and all remaining balance of my and/or my dependents' account not paid by said insurance within 45 days.  I hereby authorize the release of all information necessary to secure payment.

Signature _____________________________________   Date ______________________