Date
-
Month
-
Day
Year
Date
Patient Information
Name
*
First Name
Last Name
Social Security #
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender:
*
Male
Female
Age:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Status:
*
Single
Married
Widow
Divorce
Separate
Minor
Employer / School:
*
Occupation:
Address
Street Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
Please enter a valid phone number.
Whom my we thank for referring you ?
Reason for your visit:
Former Dentist:
Address
Street Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of last dental care:
-
Month
-
Day
Year
Date
Date of last dental X-rays:
-
Month
-
Day
Year
Date
Contacts
Home Phone Number :
*
Please enter a valid phone number.
Work Phone Number :
Please enter a valid phone number.
Cell Phone Number :
Please enter a valid phone number.
Email :
*
example@example.com
The Best Way To Contact You ?
*
Email
Text
Cell
Work
Home
In Case Of Emergency , Contact :
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Dental Insurance
Person Responsible for for Account:
Name :
First Name
Last Name
Relationship to Patient :
Phone Number
Please enter a valid phone number.
Insurance Company :
Group Number :
Is Patient Covered By Additional Insurance ?
Please Select
Yes
No
Subscriber Name:
First Name
Last Name
Relationship to Patient :
Birthdate :
-
Month
-
Day
Year
Date
Social Security #
Insurance Company :
Group Number :
Authorization
I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for servicesrendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release allinformation necessary to secure the payment of benefits. I understand that I am financially responsible for all chargeswhether or not paid by insurance.
Signature
Date
-
Month
-
Day
Year
Date
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