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?

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

Resp. Date Of Birth

Resp. Phone

Address

City

Zip Code

Resp. Social Security #

Employer

Insurance Information

Do you have Insurance?

Type Of Insurance

Take or Add a Photo of Both Sides of Your Insurance Card

Upload or drag files here

Employer

Add My Insurance Company

I.D. #

Address

City

Zip Code

Group #

Group Name

Policy Holder First Name

Policy Holder Last Name

Relation

Insured Birthdate

Social Sec. #

Phone

Address

City

Zip Code

Do You Have Secondary Insurance?

Secondary Type

Take or Add a Photo of Both Sides of Your Insurance Card

Upload or drag files here

Employer For Secondary

Add My Insurance Company

Secondary Ins. I.D. #

Address

City

Zip Code

Secondary Ins. Group #

Secondary Ins. Group Name

Policy Holder First Name

Policy Holder Last Name

Relation To Patient

Secondary Insured Birthdate

Secondary Insured Social

Phone

Address

City

Zip Code

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