www.sonomasmiles.com - New Patient Form

Signature

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Patient Registration Form
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Marital Status
Sex*
SSN / ID
Email Address*
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Drivers License
State
Number
Home Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Information
Employer
Occupation
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Method of Contact
Emergency Contact
Full Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
How did you hear about our office?
Who may we thank for referring you?

Financial Information
Patient’s Payment Details – Guarantor (Person responsible for paying the bill)
Guarantor Name
SSN / ID
Relation to Patient
Guarantor Date of Birth

MonthDayYear
Guarantor Sex
Guarantor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Guarantor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor Employer
Employer Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guarantor Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Patient’s Student Status
Student Status
College
College Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Dental Insurance Company – Subscriber and Insurance Company Details
Subscriber Name
Date of Birth

MonthDayYear
SSN / ID
Employer
Relation to Patient
Policy Number
Group Number
Group Name
Plan Effective Date

MonthDayYear
Date
Plan Expiration Date

MonthDayYear
Date
Insured Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Coverage Type
Insurance Company Details
Insurance Company
Contact Person
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Secondary Dental Insurance Company – Subscriber and Insurance Company Details
Subscriber Name
Date of Birth

MonthDayYear
SSN / ID
Employer
Policy Number
Group Number
Coverage Type
Insurance Company
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Information
Name
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medicaid Number
I authorize the dentist to release any information, including diagnosis, treatment plans/records, and radiographs, to third-party payers and/or health practitioners. I authorize and request that my insurance company (if applicable) pay directly to the dental group or dentist benefits that are, otherwise, payable to me. I understand that my dental insurance may pay less than the actual bill for service or may not cover certain treatment.

I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me or my dependents by this dental office, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies.
Signature

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

I certify that I have received an online version of Facts About Fillings and have had the opportunity to review, read and print a copy for myself.
Signature

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Patient Registration Form

Patient Information

Drivers License

Home Address

Billing Address

Work Information

Emergency Contact

Financial Information

Patient’s Payment Details – Guarantor (Person responsible for paying the bill)

Guarantor Employer

Patient’s Student Status

Primary Dental Insurance Company – Subscriber and Insurance Company Details

Insurance Company Details

Secondary Dental Insurance Company – Subscriber and Insurance Company Details

Pharmacy Information

Patient Medical History

Physician Information

Women Only

Patient’s Current or Previous Conditions

Medical Alerts

Medical Conditions

Patient’s Dental History

Previous Dentist Information

Please choose the appropriate answer