Bel Air Office	White Marsh Office	Glen  Burnie Office
4A  North Avenue, Suite 208	8114  Sandpiper Circle, Suite 207	804 Landmark Drive, Suite 126 Bel Air, MD 21014		White Marsh, MD 21236		Glen Burnie, MD  21061
(410) 879-1180	(410) 931-3350	(410) 761-9180

NOORANI AND CRAMER
O  R  T  H  O  D  O  N  T  I  C  S
O R T H O D O N T I C S F O R C H I L D R E N A N D   A D U L T S

www.GreatSmileForYou.com

Patient Information
 
Date  	
M / F
Patient’s Name  	
Last	First	Middle
Address  	
Street	City	State	Zip
Birthdate 	Home Phone 	Work Phone  	
If patient is a minor, give parent’s or guardian’s name 	Email		 Has any family member been treated or is in treatment at our office?  		
Name	Relationship
General Dentist  	
Name	Address	Phone
Whom may we thank for referring you to our office?  	

Responsible Party Information
 
Name  	       	
Last	First	Middle	Marital Status
Mailing Address  	
Street	City	State	Zip
Home Phone 	Work Phone  	
Relationship to Patient 		Birthdate				Social Security #  	  Employer 			Occupation	 Spouse’s Name				Relationship to Patient  	  Employer 			Occupation	 Social Security # 	Birthdate 			Work Phone  		

Dental Insurance Information
Policy Holder’s Name		Policy ID  	 Insurance Company 	Group No. 		Policy Holder’s Birthdate 	 Insurance Co. Address 				  I hereby instruct and direct my Insurance Company to pay the dental expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional service rendered directly to Cramer and Noorani.  Insurance benefits are not a guarantee of payment.
Patient copays are an estimate and I am responsible for any unpaid balance.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
Signature of Policyholder	Date  	

Notice of Privacy Practices
I have read and understand the office Notice of Privacy Practices, and I am aware that a copy of the policy is available upon request.
Signature	Date