Classic Dental Group

Classic Dental Group – Appointment Routing Slip

Dr. Simpson Appointment Routing Slip

Patient Name

Today's Date

Today's Visit — Procedures Performed

#	Procedure	Tooth #	Surface	Area

Today's Total Due:

Estimated Insurance Copay Fee / Installment

Appointment Notes — Today's Visit

Next Visit — Planned Procedures

Next Visit Date

Provider

#	Procedure	Tooth #	Surface	Area

Next Visit Total Due:

Estimated Insurance Copay Fee / Installment

Follow-Up Timing & Appointment Length

Days

Weeks

Months

Appt Length

Additional Notes

Payment Agreement

I, _______________________________, understand that on my next visit I will be responsible for the following payment:

Estimated Insurance Copay:

Fee / Installment:

Patient / Guardian Signature

Date

Front Desk: 1. Place fee into Payment Agreement above. | 2. Scan completed form into Appointment Routing Slip Folder in Imaging Module. | 3. Place fee in Appointment Notes Section of Appointment Window.