Daryl E. Malena DDS
10838 Old Mill Road, Suite 8
Omaha, Nebraska 68154
(402) 330-4100 (800) 825-4867 fax (402)
330-4103
Name______________________________________ Date of birth___________ Age_____
Address___________________________________________ Home phone______________
Address___________________________________________ Work phone______________
City_____________________________________ State_________ ZIP________________
Place of employment____________________________ Social Security No._______________
Insurance information (For
accuracy we can photocopy your insurance cards and keep a copy in our records)
Name of insured_______________________________________ Date of
birth____________
Place of employment_____________________________ Social Security
No.______________
Insurance company___________________________________
Group___________________
If your spouse has dental insurance, complete
the following:
Name of spouse_______________________________________ Date of
birth____________
Place of employment_____________________________ Social Security
No.______________
Insurance company___________________________________
Group___________________
If you have medical insurance that may cover
dental surgery, complete the following:
Name of insured_______________________________________ Date of
birth____________
Place of employment___________________________________________________________
Insurance company___________________________________
Group___________________
Reimbursement from your insurance company is
based on the terms of your policy with the company and not on the fee for
services provided by our office. Insurance companies are allowed 30
days for processing claims. After that time if no payment has been made,
you will receive a bill and partial payment is due to keep your account
current.
I acknowledge responsibility for the payment of my account, regardless of
insurance benefits.
I am aware that clinical photographs (showing only teeth and oral structures) are frequently taken for our records. In some cases these photographs and X-rays might be used for technical education purposes. In addition, extracted teeth and/or tissue normally removed during treatment might be used for research purposes. I understand that my name will be protected in all cases.
Signature_________________________________________
Date________________________
Parent's signature (in the case of a minor)
______________________________________________
Please do not email this form to our office. Instead, bring it to your first appointment.