Patient Information
First Name: Middle Name: Last Name:
Social Security Number: Birthdate:  (mm/dd/yyyy)
Street:
Street 2:
City:      State:      Zip:
       
Home Phone: Work Phone: Fax: Email:
Marriage Status: Gender: Minor?
Employer:
If Full Time Student, School Name: Grade:
Person Responsible for Account:


Insurance Information
MINOR CHILD - MAY NEED TO COMPLETE BOTH PRIMARY AND SECONDARY FOR PARENT INFORMATION
ADULTS - COMPLETE PRIMARY INSURED
DUAL COVERAGE? COMPLETE PRIMARY AND SECONDARY INSURED SECTIONS
Primary Insured
IF NO INSURANCE COMPLETE FOR RESPONSIBLE PARTY
First Name: Middle Name: Last Name:
Social Security Number: Birthdate:  (mm/dd/yyyy)
Street:
Street 2:
City:      State:      Zip:
       
Home Phone: Work Phone: Fax: Email:
Relationship to Patient:
Employer:
Dental Ins. Company: Subscriber #: Group #:
Secondary Insured
First Name: Middle Name: Last Name:
Social Security Number: Birthdate:  (mm/dd/yyyy)
Street:
Street 2:
City:      State:      Zip:
       
Home Phone: Work Phone: Fax: Email:
Relationship to Patient:
Employer:
Dental Ins. Company: Subscriber #: Group #:


Emergency Contact
Name:
Street:
City:      State:      Zip:
       
Home Phone: Work Phone:


General Information
Has any member of your family been treated in our office?:
Whom may we thank for referring you to our office?:
I wish to discuss the Dental Office's Financial Policy:


Payment Information
Responsible party currently has an account with this office:
Payment in full at each appointment via cash or check
Payment in full at each appointment via Credit Card

Card Type:
Card Number:
Exp. Date: