Patient Information


Thank you for choosing our dental health care team. We strive to provide you with the best possible care. To help us meet your dental health care needs, please complete these forms. If you should have any questions please ask — we will be happy to help.

PATIENT INFORMATION (CONFIDENTIAL)

Name

Cell Phone

Work Phone

Email

Home Address

City

Birthdate

SSN

Home Phone

State

Zip

Patient or Parent's Name

Who may we thank for referring you?

Emergency Contact

Phone

Previous Dentist

City and State

Phone

Family Physician

City and State

Phone

RESPONSIBLE PARTY INFORMATION

Name of person responsible for this account

Home Phone

Address

Birthdate

Work Phone

Is this person currently a patient in this office?

For your convenience we offer the following methods of payment: cash, check, Visa, Mastercard, Discover and CareCredit® Financing.

Payment is due in full at each appointment, including insurance co-payments.

PRIMARY INSURANCE COVERAGE INFORMATION

Name of Insured

Relationship to Patient

Birthdate

SSN

Name of Employer

Work #

Insurance Company

Group #

Address

SECONDARY INSURANCE COVERAGE INFORMATION

Name of Insured

Relationship to Patient

Birthdate

SSN

Name of Employer

Work #

Insurance Company

Group #

Address

PATIENT SIGNATURE

Signature of Patient or Guardian:

Date