Dr. Leah R.

Snare DDS
2510 Colby Avenue
Everett, WA 98201
Patient Legal Name: ___________________________ Date of Birth: ___________________
Preferred Name_______________________________ Age: ________________
(as it would appear on your insurance)

Drivers License #:____________________________

Male

Female

Married

Single

Child

Cell #:(_____)_____-__________ Work telephone #:(_____)_____-_____________ ext.___

Do you prefer texting for appointment reminders?

Yes

No

E-mail:__________________________________@________________________________
Home Address______________________________________________________________
City____________________________________State_________Zip___________________
Mailing Address, if different:___________________________________________________
Rent

How long at present address? ______ Years _____months Own

Landlords Name & Address:__________________________________________________

Landlords Telephone Number:(____)____-_____
Nearest Relative Not Living With You:___________________________________________
Relationship to You: _________________ Telephone #:_____________________________
Do you have insurance you would like us to bill for you? Yes

No

Your estimate portion (after insurance) will be due at each visit.

How do you plan to pay your portion? CASH
CHECK
CREDIT/DEBIT CARD
Are you the person financially responsible for this account? ___________________________
Or is it your spouse
or it is your parent or guardian

(your insurance or 3rd party cannot be held responsible for your account)

If patient is a minor, parent or guardians name :___________________________________

(Parent who accompanies children to office is responsible for payment at time of service.)

Who may we thank for referring you to our practice? _______________________________

Previous Dentist________________________Physican_____________________________

Employment Information:
Please give information for Person who covers Patient on their insurance:
Employer: ____________________________________Telephone #___________________
Address:__________________________________________________________________
Position: __________________________________How long at present employment:_____

Primary Insurance Information:

Subscriber:________________________________Birthdate:________________________
Subscribers ID #:_____-___-_____
Patients relationship to subscriber:

self

spouse

child

other

Subscribers address (if different than patient) _____________________________________

Insurance Company:_________________________________________________________
Insurance Telephone #:(____)____-_________

Group or Plan #__________________

Secondary Insurance Information:

Subscriber:________________________________Birthdate:_________________________
Subscribers ID #:_____-___-_____
Patients relationship to subscriber:

self

spouse

child

other

Subscribers address (if different than patient) _____________________________________

Insurance Company:_________________________________________________________
Insurance Telephone #: (____)____-________

Group or Plan #___________________

Consent For Services

I authorize payment of the dental benefits directly to the attending dentists office. I understand and agree
that (regardless of my insurance status) I am ultimately responsible for the balance on my account for
any professional services rendered. I have read all the information on both sides of this sheet and have
completed the above answers. I certify this information is true and correct to the best of my knowledge. I will
notify you of any changes in my health status or the above information.
Signature of patient or guardian_________________________________________________

Notice of Privacy Practices Acknowledgement

We keep a record of the health care services we provide you. You may ask to see and copy that record. You
may also ask to correct the record. We will not disclose your record to others unless you direct us to so or
unless the law authorizes or compels us to do so. You may see your record or get more information about it.
Our Notice Of Privacy Practices describes in more detail how your health information may be used and
disclosed, and how you can access your information.
By my signature below I acknowledge receipt of the Notice of Privacy Practices.
_____________________________________
Patient or legally authorized individuals signature

_______________________
date