www.dentistoakland.com - Patient Information Form

Patient Information
Patient’s Name*

First NameLast Name
Middle Initial
Name I would like to be called
Sex*
Date of Birth*

MonthDayYear
Age
Social Security Number
If patient is a minor, give parent’s or guardian’s name
Today's Date*

MonthDayYear
Who may we thank for referring you to our office?
Reason for this visit?
Responsible Party Information
Responsible Party Name*

First NameLast Name
Middle Initial
Marital Status
Residence
Street, Apt#, City, State, Zip
Mailing Address*
Street, Apt#, City, State, Zip
How long at this address
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Previous address (if less than 3 years)
Street, Apt#, City, State, Zip
How Long
Social Security Number
Date of Birth

MonthDayYear
Driver’s License Number
Relation to Patient
Employer
Occupation
No. of Years Employed
Responsible Party’s Spouse
Responsible Party’s Spouse Name

First NameLast Name
Middle Initial
Employer
Occupation
Social Security Number
Date of Birth

MonthDayYear
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Information: Relative Not Living With You
Name*
Relationship*
Address*
Street, Apt#, City, State, Zip
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Dental Insurance Information (Primary Carrier)
Insured’s Name
Insurance Co
Email
example@example.com
Insurance Co. Address
Street, Apt#, City, State, Zip
Insured’s Employer
Insured’s Social Security #
Group Number
Local Number
Do you have double dental insurance coverage?*

YesNo
Insured’s Name
Insurance Co
Email
example@example.com
Insurance Co. Address
Street, Apt#, City, State, Zip
Insured’s Employer
Insured’s Social Security #
Group Number
Local Number

Patient Information

Responsible Party Information

Responsible Party’s Spouse

Emergency Information: Relative Not Living With You

Dental Insurance Information (Primary Carrier)

Dental History

Please rank the following in the order in which they would keep you from having dental treatment

Medical History

Please check yes or no to the following which you have had or presently have

Are you allergic to or have you reacted adversely to any of the following medications?