Patient Info A

Patient, General and Insurance Information

After completing this page, please press the submit button below. Your information will be encrypted and securely forwarded, in compliance with HIPAA protocol.
Patient Name *

First Name Last Name
Preferred Name/Nickname
Date of Birth *

Month Day Year
Sex *

Female Male
Preferred Title *

Miss Ms. Mrs. Mr. Dr. None
Marital Status *

Single Married Widower Separated Divorced

Address *

Mobile Phone *

- Area Code Phone Number
Home Phone

- Area Code Phone Number
Work Phone

- Area Code Phone Number
E-mail *
E-mail - Please confirm *
Fax

- Area Code Phone Number
Social Security Number *
Occupation/Title *
Employer *
Student / Intern (if applicable)

College / Undergraduate High School Graduate / Professional Program Internship / Externship
Preferred Methods of Communications (please √ as many as you'd like):

Email Mobile phone Home phone (land line) Work phone Text message Post Card
Financially Responsible Person [FRP] Information
FRP: Relationship to Patient *

Self Spouse Guardian Parent Not applicable Financially responsible person Child
FRP: Full Name

First Name Last Name

FRP: Address

FRP: Social security number
FRP: Birth Date

Month Day Year
FRP: E-mail
FRP: Phone

- Area Code Phone Number
How did you first hear about Dr. Davis? *
If you chose Dr. Davis via cell phone, tablet, or internet search ... please detail:
Please let us know if there is someone to thank for recommending you ...

First Name Last Name
HIPAA permission is granted to: (required to allow discussion of treatment & administrative matters)
Full Name

First Name Last Name
Relationship
E-mail
Phone Number

- Area Code Phone Number
In Case of Emergency: Please Contact
If there is an emergency (please notify) *

First Name Last Name
Their relationship to you *
Their daytime phone number *

- Area Code Phone Number
Their e-mail address
Insurance Information (if applicable)
Relationship to Policy Holder: *

Self Spouse Child No insurance coverage
Policy Holder (PH) Information (if applicable)
PH: Full Name

First Name Last Name
PH: Date of Birth

Month Day Year

PH: Address

PH: Insurance Identification Number (ID#)
PH: Group Number (G#) / Policy Number (P#)
Dental Insurance Company Name
Employer / Association Information (if applicable)
Parent Company / Association
Phone Number

- Area Code Phone Number
Health Savings Account (HSA), Flexible Savings Account (FSA) Information (if applicable)
Can you participate in a HSA or FSA? *

HSA FSA No Not sure n/a not applicable
Should be Empty:

Patient, General and Insurance Information