We are very excited to see you. Let's get to know each other a little better. First, thanks for giving us your name, is there a nickname that you prefer (don't worry, we will NOT share any of this information with anyone outside the office)?
The WEO Team
Here's a picture of our team. Dr. Iuorno has been serving the West End Community for nearly 20 years and it's obvious that he loves what he does...we all do!
Detailed Patient Information
We're making progress...now let's gather some detailed information to put in your chart.
This is typically the nearest relative.
Person Responsible for Account
Primary Dental Insurance
All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize the dentist and staff to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to the dentist and staff. I permit a copy of this authorization to be used in place of the original. I give the dentist, staff, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance or payment.
Let's gather some information about your dental history.
Now for the tedious, yet most important, medical history questions. Please read carefully (we tried to make this easy for you).
All of the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.