Welcome to Abbott Family Dentistry LLC		Robert P. Pierson, DDS
PATIENT INFORMATION:
NAME: _______________________________________________________________________ SSN: __________________________________
MAILING ADDRESS: ________________________________________________________BIRTHDATE: __________________________
CITY: _____________________________________ STATE: _____ ZIP: _______________ DRIVER’S LICENSE: _________________
PHYSICAL ADDRESS: ______________________________________________________HOME PHONE: ________________________
IF SAME AS MAILING, WRITE “SAME”
EMPLOYER: __________________________________________________________________OCCUPATION:_________________________
ADDRESS: ___________________________________________________________________WORK PHONE: _______________________
CITY: _____________________________________STATE: ______ZIP: ________________CELL PHONE: _________________________ 
AT WHICH NUMBER WOULD YOU LIKE US TO CONTACT YOU: _________________________________________________
CAN WE LEAVE PRIVATE HEALTH INFORMATION ON YOUR VOICEMAIL: ________________________________________________
We will call you at the preferred number 2 days before your appointment to confirm.  
In addition, as a courtesy, we can also notify you via text and/or e-mail.  Please provide that information below:
CELL: _________________________CARRIER: ________________E-MAIL: ___________________________________________________
IF YOU ARE A FULL-TIME STUDENT LIST UNIVERSITY & CITY: _________________________________________________________________________
WHOM CAN WE THANK FOR REFERRING YOU TO OUR OFFICE: ___________________________________________________________
GUARANTOR: (PERSON RESPONSIBLE FOR PAYMENT) IF SAME AS ABOVE, WRITE “SAME”
NAME: _______________________________________________________________________ SSN: __________________________________
ADDRESS: ___________________________________________________________________BIRTHDATE: _________________________
CITY: ______________________________________STATE: _____ ZIP: _______________DRIVER’S LICENSE: _________________

EMPLOYER: _________________________________________________________________OCCUPATION: ________________________
ADDRESS: ___________________________________________________________________WORK PHONE: ______________________
CITY: ______________________________________STATE: _____ ZIP: _______________CELL PHONE: ________________________

SPOUSE INFORMATION: IF SAME AS GUARANTOR, WRITE “SAME”
SPOUSE’S NAME: __________________________________________________________ SSN: _________________________________
ADDRESS: ___________________________________________________________________BIRTHDATE: _________________________
CITY: ______________________________________STATE: _____ ZIP: _______________DRIVER’S LICENSE: _________________

SPOUSE’S EMPLOYER: _____________________________________________________OCCUPATION: _______________________
ADDRESS: ___________________________________________________________________WORK PHONE: ______________________
CITY: ______________________________________STATE: _____ ZIP: _______________CELL PHONE: ________________________
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PRIMARY INSURANCE:
INSURANCE COMPANY: ______________________________________________ PHONE: ___________________________________
GROUP NUMBER: ___________________________________I.D. NUMBER (OR SSN):____________________________________
NAME OF SUBSCRIBER: ___________________________________________________BIRTHDATE: _________________________
SECONDARY INSURANCE:
INSURANCE COMPANY: _______________________________________________PHONE: ___________________________________
GROUP NUMBER: ___________________________________I.D. NUMBER (OR SSN): ___________________________________
NAME OF SUBSCRIBER: ___________________________________________________BIRTHDATE: _________________________
ASSIGNMENT AND RELEASE:
I CERTIFY THAT I, AND/OR MY DEPENDENT(S), HAVE INSURANCE COVERAGE  WITH ________________________AND THAT I AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE CLAIMS SUBMITTED AND ASSIGN  DIRECTLY TO  DR. ROBERT P. PIERSON,  AND/OR  Abbott Family Dentistry LLC,  ALL  INSURANCE  BENEFITS, IF  ANY,  OTHERWISE  PAYABLE TO ME FOR SERVICES RENDERED.  I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE.  I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES FOR THIS OFFICE AND GIVE 
MY CONSENT FOR THE USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES, AND HEALTHCARE OPERATIONS.  I AUTHORIZE AND GIVE CONSENT FOR DR. ROBERT P. PIERSON, AND/OR Abbott Family Dentistry LLC, TO CONTACT MY EMPLOYER TO VERIFY EMPLOYMENT AND ANY OTHER INFORMATION NEEDED TO VERIFY INSURANCE ELIGIBILITY AND BENEFITS.

SIGNATURE								DATE			___________________