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Michael A. Cozzi's Patient Information Form

If you are a new patient, please complete the form below as thoroughly as possible. You may also download a printable version of the form to submit on your first visit.

Personal Information:


Patient Name





Home #

Cell #

Work #




Patient ID #

Marital Status

Patient Employer

Employer Address

Employer Phone

Emergency Contact



Contact Phone

Dental Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Company

Insurance Address

Insurance Telephone #

Group #

Insurance Subscriber ID #

Is patient covered by additional insurance?

Subscribers Name

Birth Date

Insurance Company

Group #

Dental History

Reason for visit

Date of last dental visit

Date of last dental x-rays

Please check appropriate box if you have had any of the following:

Bad BreathJaw pain or tirednessBurning sensation on tongueClicking or popping jawPain around earFood collection between teethSensitivity to coldSores or growths in your mouth Gums swollen or tenderBlisters on lips or mouthLoose teeth or broken fillingsCigarette, pipe, chew, cigarOrthodontic treatmentFingernail bitingForeign objectsSensitivity to heat Bleeding gumsLip or cheek bitingChew on one side of mouthMouth pain, brushingDry MouthPeriodontal treatmentGrinding teethSensitivity to sweets

Health History

Physician's Name



Please check appropriate box if you have had any of the following:

AIDS/HIVAnemiaArthritis, RheumatismArtificial Heart ValvesAsthmaBack ProblemsBleeding AbnormallyBlood DiseaseChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart LesionsCortisone TreatmentsCough (persistent)DiabetesEmphysemaEpilepsy Fainting or DizzinessGlaucomaHeadachesHeart MurmurHepatitisHerpesHigh Blood PressureJaundiceJaw PainKidney DiseaseLiver DiseaseLow Blood PressureMitral ValveNervous ProblemsPacemakerPhychiatric CareRadiation Treatment Respiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSinus TroubleSkin TroubleSpecial DietStrokeSwollen Feet or AnklesSwollen GlandsThyroid ProblemsTonsilitisTuberculosisTumors or GrowthsUlcerVenerial DiseaseWeight Loss

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent or guardian



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