Patient Information

Patient Information
Curtis E. Hahn, D.D.S. 4992 Wilson Avenue | Grandville, MI 49418 616.534.0135 | rivertowndental.com
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Patient Information
Personal Info
Last
First
Middle Initial
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Street Address

Address

Street Address Line 2

CityCity

State
Zip Code
Phone (home):
Cell Phone:
E-Mail Address:
example@example.com
Social Security #:
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer:
Occupation:
Phone (work):
Responsible Party Information
Last name
First name
Middle Initial
Relationship to Patient: How are you related
Social Security #:
Responsible Partys' Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Phone:
Cell Phone:
Address (if different from patient):
Insurance
Relationship to Patient:

Patient’s relationship to insured: Self Spouse Child Other please explain:
Name of Insured:
Is the insured a patient?
Insured’s Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Plan ID #:
Insured’s Address (if different from patient):
Insured’s Employer Name:
Insurance Plan Name:
Group #
Insurance Carrier Phone (Toll Free # on insurance card)
Secondary Insurance Plan Name (only if you or your child are covered by more than one insurance plan):

Self Spouse Child Other please explain: Patient’s relationship to insured:
Name of Insured:
Is the insured a patient?
Insured’s Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Plan ID #:
Insured’s Address (if different from patient):
Insured’s Employer Name:
Insurance Plan Name:
Group #
Insurance Carrier Phone (Toll Free # on insurance card)
Consent for Services
I authorize the staff of Rivertown Dental, PLLC. to perform all forms of dental treatment, medication, and therapy that may be indicated. I accept all responsibility for payment on this account. I realize that payment is due as services are rendered unless other payment arrangements have been made in writing. I consent to treatment by the staff of Rivertown Dental, PLLC.
Signature
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient:
Signature
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient:
Everyone deserves a healthy smile!
Should be Empty:

Patient Information

Personal Info

Responsible Party Information

Consent for Services