silverspringdentalarts - New Patient Form

PATIENT INFORMATION FORM

Welcome! We are pleased to see you at our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help. We look forward to working with you in maintaining your dental health for years to come.
Today's Date

MonthDayYear
PATIENT INFO
Name

First NameMILast Name
Sex

MaleFemale
Date of birth

MonthDayYear
Address

Apt #

CityState

Zip Code
Email
Home Phone

Area CodePhone Number
Cell
Work Phone

Area CodePhone Number
Age
Social Security Number
Status

MinorMarriedSingleWidowedDivorcedSeparatedPartnered for
Years
Employer/School
Occupation
Emergency Contact Name
Phone

Area CodePhone Number
Who may we thank for referring you?
PRIMARY INSURANCE
Person responsible for account
Date of birth

MonthDayYear
Relation to Patient
Social Security Number
Address

Apt #

CityState

Zip Code
Email
Home Phone

Area CodePhone Number
Cell
Work Phone

Area CodePhone Number
Employer
Occupation
Employer Address

Street Address

CityState

Zip Code
Email
Insurance Company
Insurance Address
Phone

Area CodePhone Number
Member ID
Group #
Subscriber #
Names of other dependents covered under this plan
ADDITIONAL INSURANCE
Is this patient covered by additional insurance?

YesNo
Person responsible for account
Date of birth

MonthDayYear
Relation to Patient
Social Security Number
Address

Apt #

CityState

Zip Code
Email
Home Phone

Area CodePhone Number
Cell
Work Phone

Area CodePhone Number
Employer
Occupation
Employer Address

Street Address

CityState

Zip Code
Email
Insurance Company
Insurance Address
Phone

Area CodePhone Number
Member ID
Group #
Subscriber #
Names of other dependents covered under this plan
CANCELLATIONS

Appointment times are reserved exclusively for you. In order to avoid cancellation fees, we do require, and appreciate, at least 48 hours cancellation notice. Thank you

AUTHORIZATION

I certify that I, and/or my dependents have insurance coverage with the insurance company(ies) listed above, and assign directly to Dr. Mellanie Thompson 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 authorize the use of my signature on all insurance submissions. Dr. Thompson may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature (Patient or Parent/Guardian)

Clear
Date

MonthDayYear
Printed Name
Relation

PatientParentGuardian
Should be Empty:

PATIENT INFORMATION FORM

PATIENT INFO

PRIMARY INSURANCE

ADDITIONAL INSURANCE

CANCELLATIONS