Craig E. Ball, DMD

Andrea L. Ball, DMD

Gary C. Ball, DMD

Lalaine Y. Smith, DDS

Bret A. Weathers, DDS

North

9595 Whitley Drive, Suite 100

Indianapolis, IN 46240

317-846-3463

East

4130 E 10th Street

Indianapolis, IN 46201

317-359-7244

PATIENT INFORMATION
Male Female
Single Married Divorced Separated Widowed
You Your Child
SPOUSE INFORMATION
RESPONSIBLE PARTY
PRIMARY DENTAL INSURANCE
SECONDARY DENTAL INSURANCE
DENTAL HISTORY
Yes No
CHILD HABIT HISTORY
MEDICAL HISTORY
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES OR MEDICAL PROBLEMS?
PLEASE LIST ANY OTHER MEDICAL CONDITION WHICH YOU HAVE OR HAVE HAD
FOR WOMEN ONLY
Yes No
Yes No
Yes No
GENERAL & FINANCIAL CONSENT

The undersigned hereby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize the Doctor to proceed & perform any and all forms of treatments as explained to me, prescribe & administer medication, and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that regardless of any dental insurance coverage I may have, I am ultimately responsible for payment of dental fees incurred. These fees are due and payable at the time the services are rendered unless prior arrangements have been made. The undersigned assumes and agrees to pay for all reasonable attorney fees (court costs) and other fees incurred while collecting the amount due.