PATIENT INFORMATION
Dentkos Endodontics16626 Pearl Rd. Strongsville, Ohio 44136Tel: 440-268-8445 Fax: 440-268-8443
Title:
Sex:
Male Female
Date of Birth
Marital Status:
Married Divorced Legally Separated Widow Single
PRIMARY DENTAL INSURANCE COMPANY
Patient Relation to insured:
SECONDARY DENTAL INSURANCE COMPANY
To the best of my knowledge, all of the above information is correct. I ACCEPT FULL RESPONSIBILITY FOR ALL THE TREATMENT PERFORMED AT THIS OFFICE. I understand that payment is expected at the time services are rendered. I understand that insurance coverage is a contractual arrangement between my insurance company and myself. I understand that should my account become past due, I will be responsible for all fees, interest charges, late charges and all costs of collection including but not limited to, attorney’s fees and court costs. My signature on this form authorizes the release of any information relating to claims filed on my behalf and also authorizes payment sent directly to DENTKOS ENDODONTICS, LLC.
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