Form

Patient Information

Date

Gender

Title

First Name

Last Name

Preferred Name

Birthdate

Social Security #

Cell

Home

Work

EXT

Address

City

Zip Code

Please explain

Marital Status

Appointment Preference

On Short Notice?

Time to call

For your convenience our office can communicate with you by text or email. It's okay for the office to

Patient Is (Select All That Apply)

Employed

Student

School Name

Address

City

Zip Code

In case of emergency, please contact

Phone

Relation

Who is responsible for your account?

If Other, Relation To Patient

Resp. First

Resp. Last

Responsible Date Of Birth

Resp. Phone

Address

City

Zip Code

Responsible Social Security #

Responsible Employer

Insurance Information

Do you have Insurance?

Type Of Insurance

Employer

I.D. #

If Other

Address

City

Zip Code

Group #

Group Name

If Other

Policy Holder First Name

Policy Holder Last Name

Insured Birthdate

Social Sec. #

Phone

Address

City

Zip Code

Do You Have Secondary Insurance?

Secondary Type

Employer For Secondary

Secondary Ins. I.D. #

If Other

Address

City

Zip Code

Secondary Ins. Group #

Secondary Ins. Group Name

If Other

Policy Holder First Name

Policy Holder Last Name

Secondary Insured Birthdate

Secondary Insured Social

Phone

Address

City

Zip Code

Dental Information

Reason for today's visit

Are you in pain?

For how long?

Please indicate any of the following problems by selecting the corresponding box:

If other, please explain

My teeth are sensitive to:

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to this dental office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Signature

Date

I hereby acknowledge that I have received a copy of this offices Notice of Privacy Practices. I may refuse to sign this acknowledgement. To obtain a paper copy I may request it from the office or the website.

Signature

Date