Patient Information Form

About You

Your Name(Required)

First Last

Phone(Required)

Email(Required)

Gender:

Social Security Number:

Date Of Birth:

How Did You Hear About Our Office?

Patient Referral (Name):

Address:

Street Address Address Line 2 City State ZIP Code

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Preferred Method of Contact

Your Email Address(Required)

Cell Phone:(Required)

Text message communication

Home Phone:

Best Time to Call You(Required)

Employer/Occupation:

Emergency Contact/Phone Number:

Insurance Information

Rosen Dental accepts and files all PPO insurance policies however we are OUT OF NETWORK for all insurance policies.(Required)

I have Dental Insurance and Acknowledge Insurance policy

I do not have Dental Insurance

Insurance Company:

Insurance Company Phone Number:

Name Of Policy Holder:

First Last

Date Of Birth Of Policy Holder:

Group Number

Insurance ID Number

Social Security Number Of Policy Holder:

Release of medical/dental information:

Give authorization to someone other than yourself to consult about treatment and finances. Please add person's first and last name for whom you allow.

Rosen Dental Cancellation Policy

If your appointment no longer works for you, please provide a 24 hours notice (1 business day) to avoid a $50 dollar cancellation fee. We would appreciate it very much.

Rosen Dental Office Policy

I understand that I (or guardian signed below) have primary duty to pay my doctor for services even though a portion of the fees may be payable or reimbursable by an insurance company or other third-party payer.

I understand that the determination of the dental care to be given to me by Dr. Rosen and the fees to compensate for that care are matters between my doctor and myself. These fees are due at the time that services are rendered: any balance due longer than (60) days from the date of service will be assessed at the rate of 1.5% per month as a service charge.

I understand that I am able to request a copy of the office's HIPPA Notice and Privacy Practices at any time. In addition, I realize that I can amend my privacy preferences at any time by written request via email to office@rosendentalchicago.com or in-office request.

I hereby authorize Noah H. Rosen, DMD to release my insurance company or third-party payers or its representative any information including the diagnosis and the records of any treatment or examination rendered to me.

Signature of Parent/Guardian(Required)

Date

Name

First Last

General, cosmetic, implant dentistry serving
Chicago’s Lincoln Park, Lakeview, Logan Square

Contact

2845 N Sheridan Rd. Ste 706

Chicago, IL 60657
office@rosendentalchicago.com

(773) 248-6140
(773) 248-4628

Hours

Mon 8 am - 7 pm

Tue, Wed, Thu 8 am - 5 pm

Fri 9 am - 2 pm

Select Sat 8 am - 2 pm