Patient Information for Dr. Robert Wilhite's Office

Date:
Name
Address


Birthdate Social Security # E-mail Address
Health History



Have you ever had any of the following?
Pregnancy Due Date




Dental History --- Check all that apply:
Employment Information
Referral Information

Insurance Information
Insurance

Computing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. It isimportant that you understand that this does not eliminate your financial obligation for your treatment. If your insurancecompany has not made payment to our office within 60 days, we will ask you to pay the balance due at that time. You willthen be responsible for seeking reimbursement from your insurance company. We remind you that although we will try to beinformed regarding your overall insurance plan, it is your responsibility for knowing your benefit guidelines and limitation.

Financial Policy

We are committed to providing you with the highest quality of dental care utilizing only the best materials andtechnology. Unless prior arrangements have been made, we ask for full payment at the time services arerendered. We accept cash, check, Visa, or MasterCard. Outside financing is available through CareCredit uponapplication and qualification. An interest charge of 1.5% per month will be accrued on any unpaid balance over90 days. Our bank charges us for any returned check; therefore, there will be a returned check fee of $25 for allreturned checks. We also have a broken appointment fee. There may be a charge for any appointmentscancelled with less than 24 hours notice, coming too late to be seen, or missing a scheduled appointment.In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay thereasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or withinfive (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shallbe as billed unless objected to, by me, in writing, within the time for payment. I understand that should collectionagencies or court intervention be required in an attempt to collect this debt, I am responsible for all costs incurredby Robert Wilhite, D.D.S. or its agent including, but not limited to collection agency fees and court costs.