Dela Rama Dental New Patient Form
South San Francisco & Millbrae Offices
New Patient Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Photo (Selfie)
*
Mobile Phone Number
*
-
Area Code
Phone Number
Home Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Email address
*
What is the best way to reach you?
Call Cell Phone
Text Cell Phone
Voicemail
Call Home Phone
Email
Other
Social Security Number
*
With or Without Dashes
Date of Birth
*
/
Month
/
Day
Year
Date
Marital Status (Please check all that apply)
Single
Married
Divorced/Legally Separated
Widowed
Patient Occupation
Is the patient a minor under the age of 18 years old?
*
YES
NO
Minor patient's primary living residency
Lives with one parent guardian
Lives with both parents/guardians
Other
Minor patient's school
Will someone else other than a legal guardian accompany the minor patient to appointments at our office?
YES
NO
Please list the name(s) of those who will be accompanying your child to their appointment:
Emergency Contact
Name
Phone Number
-
Area Code
Phone Number
Relationship to patient
Responsible Party & Insurance Information
Patient payment options
*
Dental Insurance/Reimbursement Plan
Patient or Parent/Guardian is Responsible Party for Payment
If you do not have dental insurance, would you be interested in an Dela Rama Dental membership plan for cleanings and emergencies, which includes discounts for further treatments?
Yes, please tell me more!
No, I am not interested.
Primary Dental Insurance
Do you have a secondary dental insurance?
YES
NO
Secondary Dental Insurance
Do you have any other dental insurances?
YES
NO
Additional Dental Insurance
Whom may we thank for referring you?
Submit
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