IN CASE OF EMERGENCY

PATIENT INFORMATION
Valley Dental Group Gentle Family Dental Care e
COMPLETION OF THIS FORM IN ITS ENTIRETY is REQUIRED AT TIME OF VISIT/TREATMENT
Name:
Birthdate:

Month Day Year
Date
Age:
Social Security No.
Address

Home Address

Street Address Line 2

City State

Zip
Home Phone:
Cell Phone:
Email:
example@example.com
How were you referred?
Employed by:
Work Phone No.
IN CASE OF EMERGENCY
Spouse/Parent:
Phone
Address:
Another relative:
Phone:
Address:
Person not Related:
Phone:
INSURANCE INFORMATION- If no insurance check here
Physician Name:
Phone:
If no insurance how to you intend to pay?
Birthdate:

Month Day Year
Date
Subscriber ID No:
How is patient related to subscriber?
Insurance Name:
Address:
SECONDARY
Subscriber's Name:
Birthdate:

Month Day Year
Date
Subscriber ID No:
How is patient related to subscriber?
Insurance Name:
Address:
Name of responsible party:
Relationship to patient:
Address

Home Address

Street Address Line 2

City State

Zip
Main Phone:
Work Phone:
Email:
example@example.com
Name of person who can authorize treatment:
Phone No.
I understand and acknowledge that I am financially responsible for the services provided for myself (or the above named) regardless of insurance coverage.

Signature of responsible party:
Date:

Month Day Year
Date
Signature

Clear
Should be Empty: