Form

Date

Gender

Title

First Name

Last Name

Preferred Name

Birthdate

Social Security #

Address

City

Zip Code

Cell

Home

Work

EXT

Check Box If

Text Okay?

Preferred Contact Method

Preferred Confirm Method

Preferred Recall Method

Appointment Preference

On Short Notice?

Please Explain

Marital Status

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

Responsible First

Responsible Last

Responsible Date Of Birth

Responsible Phone

Address

City

Zip Code

Responsible Social Sec. #

Responsible Employer

Insurance Information

Do You Have Insurance?

Type Of Insurance

Patient Policy I.D. #

If Other

Address

City

Zip Code

Employer

Group #

Group Name

Policy Holder ID #

Policy Holder First Name

Policy Holder Last Name

Insured Birthdate

Social Sec. #

Phone

Address

City

Zip Code

Do You Have Secondary Insurance?

Secondary Type

Secondary Patient Policy I.D. #

If Other

Address

City

Zip Code

Employer For Secondary

Secondary Ins. Group #

Secondary Ins. Group Name

Policy Holder ID #

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