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New Patient Intake Form
Parent/Guardian Full Name
Relationship to Ptient
Address
City
State
Zip Code
Cell Phone
Email
Dependents Full Name
Preferred Name
Date Of Birth
Dependents Full Name
Preferred Name
Date Of Birth
Dependents Full Name
Preferred Name
Date Of Birth
Dependents Full Name
Preferred Name
Date Of Birth
Dependents Full Name
Preferred Name
Date Of Birth
Emergency Contact Name
Emergency Contact Phone
who is reponsible for your account?
Account Responsible Party's Full Name
Account Responsible Party's Email
Account Responsible Party's Date Of Birth
Account Responsible Party's Phone
How did you hear about us? (Provide Name if applicable)
Insurance Information
Do you have Dental Insurance?
If you are able to, please upload an image of your dental insurance card
Upload Dental Insurance Card Front
Upload
or drag files here
Upload Dental Insurance Card Back
Upload
or drag files here
Insurance Company
Subscriber Full Name
Subscriber Date Of Birth
Group #
Subscriber ID #
Relationship to patient
Dp you have secondary Dental Insurance?
If you are able to, please upload an image of your dental insurance card
Upload Dental Insurance Card Front
Upload
or drag files here
Upload Dental Insurance Card Back
Upload
or drag files here
Insurance Company
Subscriber Full Name
Subscriber Date Of Birth
Group #
Subscriber ID #
Relationship to patient
Assignment and Release:
I assign directly to Dr. Reddish all insurance benefits, if any, otherwise payable to me for services rendered.
I authorize the use of my signature on all insurance submissions.
Patient/Parent/Legal Guardian Signature
Sign Here
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Signature Pad
Date
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Submit
Done