PATIENT INFORMATION FORM

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form. If you have any questions or need assistance, please ask us - we will be happy to help!

Patient Information

Date*

Name*

First Last

Birthdate*

Home Phone*

Cell Phone (optional)

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Employment and Marital Status

Marital Status

Patient is Employed

Employer*

Work Phone

Business Address

Street Address Address Line 2 City State ZIP Code

Spouse or Parent/Guardian's Name

First Last

Spouse or Parent/Guardian Is Employed

Work Phone (optional)

Business Address

City

Whom may we thank for referring you? (optional)

Emergency Contacts

Emergency Contact (living in the same home)*

The person we will contact in the case of an emergency

First Last

Emergency Contact Phone*

Emergency Contact (not living in the same home)

The person we will contact in the case of an emergency

First Last

Emergency Contact Phone*

Responsible Party

Someone Else Is Responsible for this Patient's Care

Name of Person Responsible for This Account*

First Last

Relationship to Patient*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone (optional)

Email (optional)

Driver's License Number*

Birthdate*

Responsible Party Is Employed

Employer*

Work Phone

This Person is Currently a Patient in Our Office

There are Other Family Members

Preferred Payment Method*

For your convenience, we offer the following methods of payment. Please check the option you prefer.

Insurance Information

Name of the Insured

First Last

Relationship to Patient

Birthdate

Insured Is Employed

Insured's Employer*

Union or Local Number

Date Employed*

Work Phone

Business Address*

Street Address Address Line 2 City State ZIP Code

Insurance Company

Insurance Group Number

Insurance Policy ID Number

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Do you have additional insurance?

I Have Additional Insurance

Name of the Insured

First Last

Relationship to Patient

Birthdate

Insured Is Employed

Insured's Employer

Union or Local Number

Date Employed*

Work Phone

Business Address*

Street Address Address Line 2 City State ZIP Code

Insurance Company

Insurance Group Number

Insurance Policy ID Number

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

I have thoroughly reviewed the information entered on this page and can confirm that all information is accurate.